Winter 2011 NE Medical Journal by Hartley Press

We never forget they’re your patients. Connect instantly to patient updates through Mayo Clinic’s Online Services for Referring Physicians Esophageal Diseases For specialized care related to benign and malignant diseases of the esophagus, look to Mayo Clinic in Florida — an internationally recognized leader in the diagnosis and treatment of gastrointestinal disorders. Comprehensive services include: • Medical and surgical treatment of all diseases of the esophagus including Barrett’s esophagus, carcinoma, gastroesophageal reflux, dysphagia, non-cardiac chest pain and others. •

Use of state-of-the art imaging techniques, including high resolution endoscopy with narrow band imaging, confocal laser endomicroscopy and other advanced systems.

•

A comprehensive Barrett’s program providing all FDA-approved treatments — photodynamic therapy, endoscopic resection, radiofrequency ablation, cryotherapy and surgical resection.

•

Esophagectomy using conventional and laparoscopic minimally invasive techniques.

•

NCI-designated comprehensive cancer center with numerous clinical trials evaluating novel tests and treatments for esophageal cancer and other gastrointestinal malignancies.

Refer to Mayo Clinic through Online Services for Referring Physicians and you’ll have the same access to lab results, radiology reports, summary letters, hospital discharges and other patient records that we do. Our secure, HIPAA-compliant, 24/7 Online Services for Referring Physicians is just one of the ways we partner with you for superior patient care. To learn more, call (904) 953-2517 or visit us online at www.mayoclinic.org/medicalprofs.

RefeRRing Physician Office 4500 San Pablo Road, Jacksonville, FL 32224 904.953.2583 | MCJRPO@mayo.edu

Inside this issue of

VOLUME 62, NUMBER 4 Internet and Medicine Winter 2011 EDITOR IN CHIEF Raed Assar, MD MANAGING EDITOR Leora Legacy ASSOCIATE EDITORS Steven Cuffe, MD Ruple Galani, MD Kathy Harris (Alliance) Sunil Joshi, MD James Joyce, MD Neel Karnani, MD Mobeen Rathore, MD James St. George, MD

Executive Vice President Jay W. Millson DCMS FOUNDATION BOARD OF DIRECTORS Benjamin Moore, MD, President Todd L. Sack, MD, Vice President Kay M. Mitchell, MD, Secretary J. Eugene Glenn, MD, Treasurer Guy I. Benrubi, MD, Immediate Past President Mohamed H. Antar, MD Raed Assar, MD Ashley Booth Norse, MD J. Bracken Burns, DO LT Orlando Cabrera, MC, USN, Resident Malcolm T. Foster, Jr., MD Jeffrey M. Harris, MD Mark L. Hudak, MD Sunil N. Joshi, MD Daniel Kantor, MD Neel G. Karnani, MD Heather Kearney, MD, Resident John W. Kilkenny III, MD Harry M. Koslowski, MD Eli N. Lerner, MD Jeannine Mauney, MD, Resident Jesse P. McRae, MD Jason D. Meier, MD, Resident Nitesh N. Paryani, MD, Resident Nathan P. Newman, MD Mobeen H. Rathore, MD Ronald J. Stephens, MD Jeffrey H. Wachholz, MD David L. Wood, MD Northeast Florida Medicine is published by the DCMS Foundation,

Northeast Florida Medicine

Features

Internet and Medicine Made Ridiculously Simple?

Daniel Kantor, MD, Guest Editor

Mind the Gap: Generational Differences in Medicine

Danielle S. Walsh, MD, FACS

Electronic Health Records: Gaining Ground & Improving Quality of Care (CME) Radley Remo, MPH and Robert Harmon, MD, MPH

Effective Communication & Marketing Strategies for Today's Busy Physicians A.J. Beson and Vanessa Wells

27 31

Social Networking: Who are Your "Friends"? Daniel Kantor, MD

HIPPA & the Internet

Christopher L. Nuland, JD

Technology for the Physician

Special Articles

Philip H. Gilbert Invited Editorial

An Overview of the Preventive Care Provisions of Health Care Reform

Danielle S. Walsh, MD, FACS

Jacksonville, Florida, on behalf of the County Medical Societies of Duval, Clay, Nassau, Putnam, and St. Johns. Except for official announcements from the County Medical Societies, no material or advertisements

Seth Phelps, Esquire

published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies. All advertising is subject to acceptance by the Editor in Chief. Address correspondence and advertising to: 555 Bishopgate Lane, Jacksonville, FL 32204 (904-355-6561), or email: llegacy@dcmsonline.org. COVER: "Fantasy Hacker" used with permission of Wallpaperhere.com.

Departments

4 5 9 35 43

From the Editor’s Desk From the President’s Desk Residents' Corner Trends in Public Health DCMS History Book

3 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

From the Editor’s Desk

Accountability in Accountable Care At my first exposure to the concept of the Accountable Care Organization (ACO), I found the use of the term “Accountable” intriguing to say the least. There is agreement that health care delivery is largely dependent on physicians who already consider themselves accountable for the quality of care. Does the name imply that this new structure places more concrete accountability measures solely on the shoulders of physicians? If so, is this a realistic expectation? I would argue that physicians should welcome more accountability as long as ACOs account for other factors that extend beyond their influence. ACO arrangements have recently achieved notoriety as a Shared Savings Program established by the Department of Health and Human Services (HHS) under the provisions of the Patient Protection and Affordable Care Act (PPACA) for Medicare beneficiaries. It is set to begin next year. The law promises to reward teams of physicians, nurses, and others who collaborate across the continuum of care to deliver improved outcomes at lower costs. The medical market is organizing in anticipation and preparing for the inclusion of commercially-insured (non-Medicare) patients in ACOs. According to industry groups, about half of physician practices were hospital-owned in 2008 with 74 percent of hospitals planning to hire more doctors in the near future. The structure of ACOs is not specifically defined in PPACA, but will likely evolve from various ingredients with different degrees of central control. All will be preparing to take on activities to focus on the integration of health care delivery to improve quality, eliminate unnecessary services and control health care costs. So, what are some of the factors that extend beyond the influence of physicians? The aging population is a large factor in the overall increase of health care costs. New technologies and treatments have extended the lives of millions, but also with significant added costs. More patients have complex psychosocial and medical issues linked with unhealthy lifestyle Raed Assar, MD, MBA choices and lack of concern for preventive care. Lack of patient adherence to medical advice or Editor-in-Chief treatment contributes to excessive spending. Additionally, physicians have to navigate a complex Northeast Florida Medicine health care system with all of its imperfections. Financial issues and a burdensome litigious and regulatory environment often overload the system and make it far from efficient. Many interventions have been proposed to help tame uncontrolled medical spending related to the aforementioned factors: patient education, case management, disease management, population health management, aligning financial incentives, shared decision making, consumer driven health plans, transparency of quality and cost measures, adherence to evidence based medicine guidelines, Integrated Electronic Medical Records (EMR), clinical decision support systems, Patient Centered Medical Home (PCMH), and finally ACOs. Regardless of how extensive this list is, it is likely to grow and morph as many ideas intertwine and return in part or whole under different cloaks. Many experts feel that all these methods have to integrate to be a viable solution. The answer has to move us all in the same direction to bend the spending curve by improving health care quality and efficiency. It is likely that ACOs will market themselves to include all of the initiatives listed above. Intuitively these initiatives, if designed well with physicians’ input, should work since most are intellectually sound. However, such initiatives may face considerable issues during implementation and beyond if they do not address insidious factors such as conflict of interest, moral hazard of insurance and misaligned benefits. From such details come larger issues which could erode effectiveness and further support. Will ACOs offer the final solution? This is a difficult question to answer. Another participant, less emphasized if we primarily place accountability on care organizations, yet playing a pivotal role in the quality and cost equation, is the patient. Patients need to be accountable. ACOs will have to develop strategies to better engage patients and help them be more accountable for their own health conditions and outcomes. What comes next? Are we likely to see an Accountable Patient Act? Have we, as a nation, embraced the betterment of our lifestyles and adherence to evidence based medicine guidelines? We will find father time serving again as both the clock and the judge. Dr. Assar is Aetna’s Medical Director for North Florida. Articles or opinions provided by Dr. Assar do not necessarily reflect the views of Aetna.

4 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

From the President’s Desk

A Swan Song with Dissonance and Harmony As I prepare to write my final “From the President’s Desk” as DCMS President, this Swan Song or my good-bye has more dissonance than I would prefer. Why? Well, it is because medicine continues to be in turmoil. The recently passed Affordable Care Act (ACA) is the subject of a consolidated lawsuit going before the U.S. Supreme Court to rule on its constitutionality (i.e., can Congress pass unfunded mandates on to the states and a few other lesser constitutional questions). This decision will come down some time in 2012, and the medical community needs to be prepared for any eventuality. If the Supreme Court rules the ACA is constitutional, then the full implementation begins in 2014. However, if the Court rules against part or all of the ACA, what will physicians do? The other urgent issue continues to be the so-called Medicare formula referred to as the Sustainable Growth Rate (SGR) which needs to be completely revamped. SGR is likely to be in deliberations by the Committee of Twelve whose responsibility it is to find additional cuts to the federal budget, or deficit reduction, of approximately one and a half trillion dollars. This Committee’s deadline is Thanksgiving of this year. What can you do? Write your representatives and senators. Also, support organized medicine that is lobbying on your behalf. And whether you like or do not like the ACA, it will likely prove to have a profound impact on medicine and the healthcare delivery system for years and decades to come. Finally, there is no question that we need a permanent fix to the SGR, replacing it with a sound economic model. Malcolm T. Foster, Jr., MD 2011 DCMS President

The DCMS will need its entire membership and key leaders to rally behind those state and national legislators who champion the right causes for medicine and the medical profession.

Now to the harmonious part of my Swan Song. Let me take this opportunity to salute two longstanding physician leaders in our community. One is Dr. Robert Nuss, the retiring University of Florida Dean for the University of Florida College of Medicine, Jacksonville. His counsel to DCMS leaders and support of DCMS membership for his faculty has been invaluable. The other is Dr. Yank D. Coble Jr., Director of the University of North Florida Center for Global Health and Medical Diplomacy. He has been championing efforts to increase the number of residency positions in North Florida with an emphasis on primary care. It is an age old debate, but one Dr. Coble and his Biosciences Council are addressing admirably. And as my DCMS presidency comes to an end, I want to thank a hardworking DCMS Board of Directors and Executive Committee, the officers, and the committee chairs and members. Also, my thanks to the DCMS Alliance for its continuing support of DCMS programs and activities. In particular, I want to thank Jay Millson, our Executive Vice President, who speaks for all of medicine and does it well. The DCMS also has a wonderful staff in Patti Ruscito, Barbara Braddock, Marigrace Doran, Leora Legacy and Deana Hadden, each of whom plays a vital role in accomplishing the DCMS Mission “to promote the delivery of and access to high quality, ethical medical care for the community, and to serve as an advocate for physician members and their patients.” All of the groups and people I have mentioned have worked hard this year to represent you, the physicians of Duval County. Every effort has been made to ensure that the practice of medicine remains a noble profession and the patient physician relationship continues to come before politics and questionable public policy. It has been my pleasure to serve as president of this storied medical society, and I look forward to assisting my successor, Dr. Ashley Booth-Norse, and others in supporting the medical profession in Northeast Florida.

The 2011 DCMS Annual Meeting is December 1, 2011. See full coverage in the next journal issue. 5 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Offering the most comprehensive care possible so our patients can achieve the most complete recovery possible.

BrooksRehab.org

With expertise in treating stroke, spinal cord injury, hip fracture/orthopedics, pediatrics, and brain injury, Brooks Rehabilitation offers a full continuum of services to support patients, including: •

One of the largest inpatient rehabilitation hospitals in the Southeast

•

A network of 26 outpatient clinics with specialties in Sports Therapy, Balance, Orthopaedics, Women’s Health, and Chronic Pain

•

An established home health services division

•

A cutting-edge research facility

•

An award winning skilled nursing and rehabilitation facility

•

A physical medicine & rehabilitation physician practice

•

An extensive array of preventive, educational, and community-based services such as adaptive sports and the Brooks Clubhouse.

Rehabilitation Hospital • Skilled Nursing • Home Health Care • Outpatient Therapy • Research • Community Programs

6 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

7 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Philip H. Gilbert Invited Editorial

The Changing Face of Medicine John F. Lovejoy, Jr., MD - 1988 DCMS President and Life Member Editor's Note: Philip H. Gilbert served as the Executive Vice President of the Duval County Medical Society (DCMS) from 1984 until his unexpected death in 2004. During those decades, he was an outspoken advocate for the physicians he served and for the needs of their patients. With no fear of retribution, Phil shared his honest informed opinions with his DCMS colleagues and with the community they served. In his honor, the DCMS Board of Directors established the Philip H. Gilbert Invited Editorial to celebrate his spirit for addressing issues that he championed such as advocacy, tort reform, community activism and caring for the underserved. The “Request for the 2011 Philip H. Gilbert Invited Editorial” invitation was sent in July to local, state, and national leaders (physician or layperson). All editorials received were reviewed by the DCMS Journal and Communications Committee. Two editorials were chosen for publication - one in this issue and the other was published in the last journal.

Doctor and Patient Changes

With three generations of physicians in my family, I have seen the face of medicine change. My dad, Dr. John F. Lovejoy, Sr., frequently brought home food given to him in payment for medical services. House calls and weekend rounds were a usual thing, and as a young boy if I behaved, I could go with my father to see his patients. HIPPA would not allow that now. And today, to get a house call you would have to join a practice that charges monthly service fees.

John F. Lovejoy, Jr., MD DCMS Past-President

The doctor used to be respected in society and still is, but the expectations in the relationship were different. The doctors used to wear professional clothes and carried black bags. The patient addressed the doctor as “Doctor”, not a provider, and his/ her suggestions were usually followed without multiple second opinions.

The practice model used to be individuals or small specialty groups. Now, there are few individual practitioners. Sadly, physicians gave up their independence because it was more profitable and less stressful to have a hospital or managed care group handle the paperwork headaches. I am sure it makes life easier for the doctor, but the patient relationship is less personal and more rushed. Interestingly enough, the administrators now make more money than the doctors and have more control over the doctors’ lives.

Hospital and Healthcare Changes

There have been changes in the hospital system as well. I don’t remember anyone being denied care, but hospitals were different and not as sophisticated. When I started practice in the early 1970s, the hospital had one administrator, a head nurse and department heads. The patient employee ratio was less than one to one. Now there are more employees per patient and many sublayers of administrators. I know medicine has progressed and 8 Vol. 62, No. 4 2011 Northeast Florida Medicine

is more complex, but it seemed to work well when the nurses made rounds with the doctors and pertinent information was entered in a chart, not a template so the hospital can get maximum reimbursement. Time was spent with the patients, not on the computer. That is not to say that progress is bad, but the all-important patient contact and empathy, communication and personal touch that is part of the healing psyche is often overlooked. Instead, time is spent meeting all the regulations, mandates and requirements of the present system. The brightest and most interested youth were able to be aides in the hospitals and clinics and could observe surgery and treatment without HIPPA’s interference. With this hands-on experience, they were often stimulated to follow a physician or some other healthcare professional into a medical career. Now it is almost impossible to give them that exposure.

Questions and Conclusions

Where is medicine going? I am not sure. It will always attract those who have compassion for others. But, will they be able to provide the type of care as in past generations? I think not. Technology, innovation and society will demand a different type of care that is less personal, more streamlined and burdened with government restrictions and public relations concerns. I am proud to have practiced when I did and hope the next generations do not lose that patient/doctor relationship that made the medical profession one of the most important parts of my life. Is there a solution that will make these changes palatable? Yes, it is an age old solution; “Get involved!” To ensure all of the changes work for and not against the profession, it takes involvement with patients, civic groups, the community, and, most importantly, within organized medicine. Those of us in the medical profession can still control our future. But it won’t happen if we leave our fate to the politicians and lawyers because they are looking out for their own interests. We must advocate for our patients and the medical profession. Such advocacy can only happen as we get involved and stay active in DCMS and other professional groups that can direct us wisely in an ever changing medical environment. www . DCMS online . org

Residents’ Corner: St. Vincent's Family Medicine Editor’s Note: In an effort to connect more Duval County Medical Society members with residents, in each 2011 issue there has been a “Residents’ Corner” with information about a residency program in the area, details about research being done and/or a list of achievements/accomplishments of the program’s residents. This “Residents’ Corner” features St. Vincent's Family Medicine Residency Program.

Overview of Residency Program

St. Vincent’s Family Medicine Residency Program was developed in 1972 and has been a successful program ever since. The program hosts 30 residents in total, with full-time OBs, a maternity-trained family physician, pediatrician, psychologist, and 10 family medicine faculty. In addition to the full-time faculty physicians, the residents receive teaching from a complete spectrum of private practice physicians who have a dedication to resident education. There are 34,000 clinic visits, 322 deliveries and 2,000 hospital admissions annually. The program emphasizes outpatient care and continuity and is designed to develop critical clinical skills and decision-making abilities. An Electronic Health Record (EHR) has been fully implemented since November 2006. Over 100 graduates are currently practicing in the Jacksonville area. St. Vincent’s Family Medical Center (SV FMC) embraces the patient centered medical home (PC-MH) in its approach to providing comprehensive primary care for children, youth and adults. It has developed the characteristics of the PC-MH by providing each patient with a personal physician who is trained to provide first contact, continuous and comprehensive care, through the use of registries, clinical information systems that track referrals, lab results, and templates to guide clinicians through evidence-based treatment recommendations. SV FMC also supports patient self-management through group visits such as birthing classes, diabetes and renal education classes, and nutrition consultations. Care is coordinated seamlessly from the clinic to the hospital and nursing home. EHR help to reduce medical errors, improve patient care, and facilitate work flow processes for optimal productivity. The Family Medicine Residency Program is part of St. Vincent’s Health System, which was founded by the Daughters of Charity in 1916. St. Vincent’s is a member of Ascension Health, the nation’s largest Catholic and nonprofit health system.

Community Outreach

Mobile Health Unit St. Vincent’s Mobile Health Outreach Ministry is a doctor’s office on wheels that travels throughout the region to minister to adults and children. From migrant farm workers in Putnam County to inner city children in Duval County, the Mobile Health vans reach the isolated and the underserved with immunizations, health screenings, physicals, laboratory and diagnostic testing and many other services. In a typical year, St. Vincent’s HealthCare provides medical care to more than 7,800 individuals and the demand is growing. This includes more than 800 school and summer program physicals for children, including immunizations, each year. Haiti Every year since 1980, several physicians and surgeons travel to St. Boniface Haiti Foundation at Fon Des Blanc Hospital to provide medical care to the needy. The surgical team visits the hospital monthly, and a pediatric team travels there annually. Seton Center for Women and Children The goal of the Seton Center is to offer new moms and families consistent information and support in pregnancy. The center provides information and classes regarding childbirth, breastfeeding and newborn care. Newborns come to the center routinely for postpartum assessments at 3-5 days of age. Reach Out and Read Reach Out and Read prepares America’s youngest children to succeed in school by partnering with doctors to prescribe books and encourage families to read together. Doctors, nurse practitioners, and other medical professionals incorporate Reach Out and Read’s evidence-based model into regular pediatric checkups, by advising parents about the importance of reading aloud and giving developmentally-appropriate books to children. The program begins at the 6-month checkup and continues through age 5, with a special emphasis on children growing up in low-income communities. The annual Read and Romp, a family event where children participate in games, activities and crafts stations, takes place each fall.

Resident Honors

Dr. Lara Church was awarded the AAFP Foundation Pfizer Immunization Awards Program 2011 for Immunization Coverage of 90-94% of 2-year-old children in the pediatric population at St. Vincent’s Family Medicine Center. Dr. Lindsey Westberg was recognized as a FAFP Foundation Exceptional Resident Scholar 2011 for her outstanding work as a third-year resident. Drs. Lindsey Westberg and Ross Jones have served as Presidents of the Florida Association of Family Medicine Residents (2010 - present) Dr. Heather Kearney is a third year resident at St. Vincent's Family Medicine Residency Program in Jacksonville, FL. Dr. Kearney served as the program's resident representative to the DCMS Board of Directors for the 2010-2011 year. She is a graduate of the University of South Florida College of Medicine and plans to enter private practice in the fall of 2012.

9 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

10 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

This Issue’s Focus: Internet and Medicine

Internet and Medicine Made Ridiculously Simple? iPads, iPhones, Droids, Blackberrys … the world has changed forever with the dizzying array of new modes of communication made possible by the computer chip. Yet, computers are a fairly new invention in the history of mankind. From Turing’s thought experiment in 1936 on a theoretical device that manipulates symbols on a strip of tape according to a table of rules, to my alma mater’s (University of Pennsylvania) ENIAC (Electronic Numerical Integrator And Computer) designed to calculate artillery firing by the United State’s Army in 1946, to IBM mainframe computers, to PCs and then to handheld devices…computing technology has advanced at a dizzying speed. While Medicine has embraced aspects of the Digital Age, such as robotic surgery and telemedicine, other elements of the Information Age have only been accepted half-heartedly. Look at the uphill battle faced by Electronic Medical Records and Health Information Exchanges. Meanwhile, society has progressed even further to the Social Media Age, and physicians are often lost in a confusing array of new terminologies. In this issue of Northeast Florida Medicine, Danielle S. Walsh, MD, tackles the generational gaps explaining much of how physicians see the world and interact with colleagues, family and patients. In her article, “Mind the Gap: Generational Differences in Medicine,” she emphasizes that the value in understanding the important differences between Baby Boomers, Generation Xers and Millennials is crucial to the physician recruiting process. Regardless of generational differences, Radley Remo, MPH and Robert Harmon, MD MPH, recognize the need to update all physicians on the new reality of Health Information Technology (HIT) terminology and Electronic Health Records (EHRs) in their article, “Electronic Health Records: Gaining Daniel Kantor, MD Medical Director, Neurologique Ground and Improving Quality of Care.” This article is approved for Continuing Medical Education (CME) credit. Harnessing the internet may seem foreign to less computer savvy physicians , but in an article entitled, “We All Need to Listen,“ A.J. Beson and Vanessa Wells argue that “You want your patients interacting with you. You want an easy and natural flow of two-way communication between your patients and your brand.” Like any tool, there are potential dangers and we need to protect our patients’ and our own safety. In “Social Networking: Who Are Your ‘Friends?’,” this Guest Editor explores practical issues surrounding the use of social networking, and I weigh the advantages and disadvantages of entering the worlds of Facebook and Twitter. Despite the advantages of interacting online, there are potential legal ramifications to your use of the internet, which is explored by Christopher L. Nuland, JD, in his article, “HIPAA and the Internet.” Legal and regulatory pitfalls are weighed against how “interactive patient portals save staff and provider time and can lead to happier patients, who often can obtain vital information without having to wait for routine appointments.” Finally, Danielle S. Walsh, MD, further helps to close the generational gap by giving practical suggestions in “Technology for the Physician". The authors and I have ensured that the articles in this issue of Northeast Florida Medicine are current as of December 2011, but we also caution you that the internet, a medical tool, is changing rapidly just as all medical technologies do. The future of medicine may rest in cognitive computing as heralded by the Jeopardy champion, Watson.1 Now, more than ever, the foundation laid out by the late Steve Jobs, co-founder of Apple, remains true, that “Innovation distinguishes between a leader and a follower.”2 Sources:

http://technewsworld/stort/68678.html http://blog.subconsciousfilms.com

1 2

Special thanks to wallpaperhere.com for permission to use "Fantasy Hacker" for the cover art. 11 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Mind the Gap: Generational Differences in Medicine Danielle S. Walsh, MD Abstract: This article seeks to address the generational differences between Baby Boomers, Generation Xers and the Millennials and the void this creates in the medical environment. The differences will be analyzed by reviewing the information available, extrapolating from other industry, and providing insight into the implications of generational issues in medicine.

Introduction The current physician work force consists largely of three generations, the Baby Boomers, Generation Xers, and the Millennials. The fourth generation, the Traditionals or PreBoomers, have largely retired and play a significantly smaller role in the dynamics of the physician workforce. For each generation, differences in historical events and social norms in childhood and adolescence manifest as divergent priorities, values, and career expectations. These dichotomies are known to create misunderstandings and conflict in the workplace, but little attention is paid to understanding the underlying differences, particularly in the medical arena. Physician recruitment and retention are areas in which tailoring efforts to different generations can significantly improve success. It’s no secret that groups of people born in different time periods with varying external influences develop somewhat divergent viewpoints in priorities, preferences, and values. Scientists who study social and demographic trends note that the differences in the currently identified four generations in the workforce are among the most dichotomous reported.1 Leveraged by the entertainment industry and marketing firms for decades to target their products, these generational differences can, and do, create significant friction when not recognized and addressed. The physician world has been slower than some fields to study the impact of these differences on the profession. In 2006, the Online Journal of Issues in Nursing dedicated an entire issue to the impact of generation differences on the nursing world, but this topic has had limited visibility for physicians.2 Yet, the impact of generation difference is felt in hiring, work habits, financial decisions, and even patient interactions.

Generational Groups In order to study differences in generations, it is necessary to make generalizations about large groups

Alexander Dumas once said, “All generalizations are dangerous, even this one”.

Address Correspondence to: Danielle S. Walsh, MD, East Carolina University, 600 Moye Blvd, PCMH TA-207, Greenville, NC 27834. Email: walshd@ecu.edu. 12 Vol. 62, No. 4 2011 Northeast Florida Medicine

of people. Demographic profiles are created by categorizing people with similar historical events and social influences during a particular age in life. An example of this is the descriptor “Generation X” for describing people born between 1965 and 1980 and exposed to the Cold War of the 1980s as adolescents and young adults. While not every person who fits that demographic profile will conform exactly to the characteristics of the group, it’s important to note that these categorizations are not about the individual person, but rather the collective. Additionally, the nomenclature in the study of generation differences lacks standardization, resulting in one study calling a generation “Generation Y” while another reporting on the same demographic calls them the “Millennial Generation” or “Gen Me.” Despite these small differences, the outcomes, characteristics, and interpretations of trends in these groups tend to be consistent and reproducible across the field. Table 1 summarizes the four generations currently encountered in medicine.

Table 1 Demographics of the Generations3 Traditionals • Born 1925 to 1944 • Ages 66 and up • 40 million

Generation Xers • Born 1965-1980 • Ages 30-45 • 61 million

Baby Boomers

Gen Y or Millennials

• Born 1945-1964 • Ages 45-65 • 79 million

• Born 1980-2000+ • Ages under 30 • 43 million

Traditionals, also known as Pre-Boomers, were born in the Depression Era and represent a fairly small population, largely due to poverty engendering lower birth rates. Most members of this group have already entered retirement and play less of a role on the current physician work force. Baby Boomers are named for the post World War II population boom that occurred in a period of relative prosperity in the US. This generation is by far the largest demographic in the work force, though the first members of the group are now in their late 60’s and entering retirement. Significant influences on Boomers include the culture of the 1960s, the assassinations of President John F. Kennedy and Dr. Martin Luther King, Jr., the Watergate scandal, and the turbulent Korean and Vietnam wars. Generation X is one of the smaller generational populations and was influenced by, not only the www . DCMS online . org

Cold War, but also by the Iranian hostage crisis, economic recessions, and the Challenger space shuttle explosion. The last generation in the current work force, Generation Y, has seen the rise of terrorism and economic instability. Sentinel historical events for this group include the Columbine shootings and the 9-11 terrorist attacks. Establishing the characteristics of a particular generation requires that its members have enough economic and social separation from their parents to make independent decisions. Thus, the up and coming generation remains an unknown quantity until young adulthood.

Generational Priorities and Values With each generation come distinct priorities and values that shape their decisions and actions. For example, Boomers grew up in large, highly competitive classrooms where academic success was essential. The competition played a significant role in future career choices. This contrasts with the “Everyone is special” message of the Gen X classroom and the decreased emphasis on grades alone as a measurement of potential. Gen Y found their childhood filled with structured play dates, scheduled afternoon activities and sports, and increased involvement of their parents in the oversight of their education. The impact of the varied historical and social influences can be seen in the priorities of each demographic in adulthood. Boomers value working hard, being honest, and maintaining integrity. But “Being Happy” is the primary aspiration of the Gen X. They also focus on being “true to yourself ” and expressing individuality. Gen Y were consistently told they could be anything they wanted to be, and manifest this as confidence and pursuit of setting short term, satisfying goals, all the while ensuring there is good work/life balance.4 The impact of these different motivations and values become apparent when the three dominant generations converge in the workplace. For the employer, an understanding of these motivations is useful for recruiting, retaining, and generally maintaining employee satisfaction. Boomers are the most likely to embrace the corporate culture of their respective workplace. Once a member, they readily seek promotions, responsibility and the authority it brings, and anticipate a pay raise with each respective promotion. Their profession is much of their identity in that their career is the dominant component of how they perceive themselves and want other to perceive them.5 Many value owning their own medical practice and view the ability to do so with a profit as success. Communication is by formal meetings, formal letters, phone calls and some email. Dress is typically business formal. Continued education in their field is via print journal, textbooks, and attendance at live CME presentations. Time outside the office may include active involvement in professional groups, such as the local medical association or philanthropic organizations, and their spouses often join them in supporting these efforts. Maintaining a Boomer in 13 Vol. 62, No. 4 2011 Northeast Florida Medicine

the workplace involves ensuring they can continue to move up the leadership ladder and providing opportunities to control the working environment. Many respond well to incentive programs based on duration of employment and productivity. Generation X brings a striking contrast to the workplace. They tend to view medicine as a job through which they make a living and achieve personal goals, as opposed to an identity. Despite valuing learning new skills and interest in new technologies, they are not necessarily interested in leading the team or becoming “the boss.” Most favor employee status where the issues of rent, overhead, and billing are handled by other individuals. Once no longer challenged or faced with an undesirable work environment, most will elect to move on rather than await change. Their relaxed approach to work will manifest as casual dress, speech, and communication. With a focus on technology and evidence-based medicine, this group does a web search for every topic, watches videos of new procedures or devices, and limits memberships in professional organizations to those that provide a tangible benefit. Gen X employees generally change jobs every 5 years.6 Recruitment and retention of this generation involves careful attention to work/life balance and allowing freedom to determine work hours within a structure of expected volume and productivity. They respect a boss not because of his/her title or years of experience, but rather on the basis of performance, skills, and ability to assist employees on achieving their individual goals. As students they were encouraged to ask “why” and this tendency does not disappear at entry into the workforce. Micromanagement is discouraged, explanations are encouraged, and the opportunity to bring new skills and services to the group is valued by this demographic.7

Gen X is likely "to believe the boss should impress them in order to keep them...."8 The Millennials, newest generation in the workplace, experienced a childhood emphasizing working as a team with credit for victories and accomplishments being distributed to all members of the team. They thrive under a well-defined structure with detailed guidance and clear rules. Like Gen X, they espouse a highly technical but informal style of communication, best demonstrated in their use of smartphones and texting for managing their personal and professional lives. Though demanding of themselves and others, they thrive on frequent, positive feedback and anticipate promotion and salary raises at frequent intervals. The restriction to an 80-hour work week or less in training has been the norm, and the expectation of a reasonable work/life balance is engrained. Electing for additional time off over opportunity for additional income, Millennials are likely to use some of this time for volunteerism in indigent care and medical mission trips.9 Part-time positions are of interest to both women and men, www . DCMS online . org

with 13% of male and 36% of female physicians practicing part time in 2010, compared with 7% and 29% in 2005.10 Most have eschewed joining organizations just for the sake of membership; they need a clear sense of identity within a group, a voice at the table of leadership in the association, and the belief that their efforts will bring value and change. Their inquisitive nature and free-spirited quest for adventure may translate into frequent job changes, with some staying in positions for only 2-3 years at a time.11 Few are interested in taking on the cost, challenges, and lifestyle of a physician owned practice.12 The technology “divide” is one area in which the generational differences can be staggering. While many Boomers may use email comfortably, others have an account, but allow their secretary to print out the message and place the paper note on their desk. Their response may even be dictated. Fewer are facile with editing and uploading videos and many are uncomfortable sharing credit card numbers and account information online for purchases and banking. Many prefer a written check or a personal bank interaction for transactions. Generation X readily embraces online shopping and accounts, viewing the electronic secure sites as more reliable than the human or paper worlds. Millennials carry this a step further and perform financial transactions via smartphone, and are likely to embrace the integration of credit cards into their hand-held device.

Generational Differences When Recruiting Not surprisingly, the differences in generational values and priorities can become more apparent during the recruitment of a new physician into a medical practice. In placing a job ad to recruit a partner, Boomers tend to write ads that would appeal to them, even if seeking a junior partner. Figure 1 contrasts the type of job listing likely to appeal to the different demographics. Consideration should also go into the medium in which the ad is placed. Boomers head to the classified section of the prominent journals in their field or allow a recruiter to perform the search on their behalf. In contrast, Generations X and Y head directly to the internet to begin and end their job search – all but ignoring the print versions of the journals containing the ads. The quality of the potential employer’s website and the amount of information it contains about the position factor into whether they even inquire further. Other media likely to catch the attention of the younger generations include Twitter job postings, video announcements, and Facebook pages. Once a candidate for a position is found to be a good fit, generational preferences should also be considered for development of the contract. Boomers strive to negotiate the highest salary, a strong bonus incentive, often desiring a short buy-in period to a private group, and paying close attention to retirement programs. Gen y will accept a slightly lower salary if balanced by a significant amount of vacation 14 Vol. 62, No. 4 2011 Northeast Florida Medicine

Figure 1 Job Listing Samples (Appeals to Boomer generation) Surgeon

The University of ____ is seeking a General Surgeon to join the prestigious faculty of this top tier academic program. The candidate will pursue basic science research in addition to teaching and clinical responsibilities. Candidates should be board certified or board eligible. Rank and salary is commensurate with experience. Submit curriculum vitae and two letters of recommendation to: John Smith, MD, FACS Chief, Department of Surgery 100 Main Street City, State 12354 (555) 555-5555

(Attracts a Gen Y Physician) The Job of Your Dreams!

Bring your cutting edge surgical techniques to our growing surgical practice and find the work/life balance you’ve always dreamed of. With our talented team of physicians, residents, and in house critical care physicians, your patients will be well cared for. Our city is family friendly and offers opportunities for enjoying the arts, theatre, and sports. A generous compensation and relocation package round out this unique opportunity. Explore this opportunity and more at our website funjob.com or email your resume for immediate review to jsmith@funjob.com.

time, supplements for training and travel to conferences, and access to cutting edge technology.13 Companies that believe a standard, one-size fits all package should be offered to all employees without consideration of the priorities of the applicant, may quickly find that they have limited their search to a single “type of applicant” and fail to understand why the position goes unfilled for years. Experts agree that the secret to a stable physician workforce is largely in understanding the generational differences and avoiding perceiving them as either good or bad.14 Diversity should be welcomed and programs to encourage productivity and career satisfaction should be individualized, a sometimes challenging endeavor in larger organizations that tend to favor a single standardized policy. Leaders need to be approachable, provide frequent and specific feedback, involve others in critical decisions, and encourage initiative and new ideas from all demographics.15,16 A keen awareness of work/life balance and flexibility in work schedules, while maintaining productivity standards, are also helpful in tailoring to each group. In contrast, demands that younger generations simply conform to the norms set by the Boomer generation are likely to www . DCMS online . org

fail after a time. Advertising, interviewing, and on-boarding a new physician is a remarkably expensive endeavor, estimated to cost over $226,000 per physician.17 In recognition of this, it makes sense to make every effort to retain the physicians brought on board and avoid the fees associated with a search.

Conclusion Exploring the impact of having multiple generations in the workplace, with an eye towards understanding norms accommodating differences where possible, can prove beneficial for all physician groups. Baby boomers thrive in formal atmospheres and work towards positions of increasing prestige and leadership. Generation X is most productive when allowed flexibility in a relaxed setting that incorporates the use of technology to produce efficient outcomes. Gen Y values

Dr. Jean Twenge said, "Asking young people today to adopt the personality and attitudes of a previous time is like asking an adult American to instantly become Chinese."18 a team approach with guidance, but places great emphasis on work/life balance. While it may seem easiest to expect all generations to conform to a single work paradigm, employers with such expectations may find difficulty when recruiting, experience high turnover, and have to deal with continuing employee dissatisfaction.

Resources

• Deal, Jennifer J. Retiring the Generation Gap. John Wiley & Sons. San Francisco, California. 2007. • Orrell, Lisa. Millennials Incorporated. Intelligent Women Publishing/Wyatt-MacKenzie Publishing, Deadwood, Oregon. 2007. • The Center for Generation Studies, www.gentrends. com. Accessed 2009.

References

Associated Press. Study: Generation gap in U.S. largest since ’60s. Available at: http://www.msnbc.msn.com/id/31598018/ ns/us_news-life/t/study-generation-gap-us-largest-s. Accessed September 17, 2011.

Sherman R. Leading a Multigenerational Nursing Workforce: Issues, Challenges and Strategies. Online Journal of Nursing 2006 May 06 11(2). Available at: http://www.nursingworld. org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/TableofContents/Volume112006/No2May06/ tpc30_216074.aspx. Accessed September 17, 2011.

United States Census Bureau. Available at: http://www.census. gov/compendia/statab/2011/tables/11s0007.pdf. Accessed September 17, 2011.

Zemke R, Raines C, Filipczak B. Generations at work: Managing the clash of veterans, boomers, Xers and Nexters in your

15 Vol. 62, No. 4 2011 Northeast Florida Medicine

workplace. Amacom, New York,New York. 2nd ed. 2000. 5.

Value Options. The Baby Boomer Generation [Born 1946–1964]. Available at: http://www.valueoptions.com/ spotlight_YIW/baby_boomers.htm. Accessed September 17, 2011.

Mezzapelle D. Generation Y Going to Work – Hopefully. Available at: http://blog.goliathjobs.com/2008/10/25/ generation-y-going-to-work-hopefully. Accessed September 17, 2011.

Value Options. Generation X [Born 1965–1980]. Available at:http://www.valueoptions.com/spotlight_YIW/gen_x.htm Accessed September 17, 2011.

Gravett L, Throckmorton R. Bridging the Generation Gap. Career Press. Franklin Lakes, New Jersey. 2007.

Ladika S. Bridging generations: How your club can attract new age groups. The Rotarian. 2008 Sept; 187(3):27-28.

10. CejkaSeach.Available at:http://www.cejkasearch.com/news/ media-mentions/part-time-doctors-shaking-up-smallpractices. Accessed September 17, 2011. 11. Robert Half International. What Millennial Workers Want: How to Attract and Retain Gen Y Employees. Available at: http://www.rhi.com/GenY. Accessed September 17, 2011. 12. Stagg-Elliott V. Ownership loses its luster. American Medical News. 2009 Oct 26;52(23):23-24. 13. Arbel T. Millennials value time off, pay more than Gen X. Available at: http://www.msnbc.msn.com/id/35783784/ns/ business-personal_finance/t/millennials-value-time-pay-moregen-x. Accessed September 17, 2011. 14. Stagg-Elliott V. Generation gaps. American Medical News. 2010 June 21; 53(12):20-1. 15. Mocke D. The Generation Gap and Motivation. Available at: http://www.sustainable-employee-motivation.com/ generation-gap.html. Accessed September 17, 2011. 16. Smith G. Baby Boomer Versus Generation X: Managing the New Workforce. Available at: http://thecitizen.com/archive/ main/archive-010509/business/b-03.html. Accessed October 8, 2007. 17. Buchbinder SD, Wilson N, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care 1999 Nov: 5, 11:1431-8. 18. Twenge JM. Generation Me. Simon & Schuster. New York, New York. 2006.

While it may seem easiest to expect all generations to conform to a single work paradigm, employers with such expectations may find difficulty when recruiting, experience high turnover, and have to deal with continuing employee dissatisfaction.

www . DCMS online . org

Trends in Public Health

The Internet and Public Health Niketa Walawalkar, MD, MPH; Thomas Bryant III, MSW; and Robert Harmon, MD, MPH Computers and the Internet have become a daily aspect in our lives, making it easy to search for information and keep up with the activities of the world. The Internet is increasingly utilized by researchers, health care professionals and the general public to seek health-related information. The Internet also provides a medium to allow mass communication for health campaigns, generate consumer awareness and influence health behaviors. The National Center for Health Statistics recently found that 74% of all U.S. adults use the Web and 61% have looked for health or medical information on the Internet. Public health organizations around the world use the Internet to keep communities informed about their health and well being. Web technology offers new capabilities for people committed to protecting and promoting the public’s health, from combining data resources for detecting and monitoring early outbreaks of infectious diseases to using social networks for information sharing. A study by the Centers for Disease Control and Prevention (CDC) demonstrated that using a website to display health-related information is an effective means to inform people and it serves as an important public health tool for community outreach1. The Florida Department of Health (DOH) seeks to incorporate internet technology into its services. (www.doh. state.fl.us) The Vital Statistics division uses “e-vitals” to allow consumers to request and print birth certificates via the Web. The Environmental Health (EH) office and many county health departments have online service request forms to expedite environmental services. EH is also planning to replace the current paper-based tracking of food, water and arbovirus borne diseases with a new web-enabled system that will be integrated with the DOH disease surveillance systems. The DOH Epidemiology unit now uses an electronic laboratory reporting system that facilitates sharing laboratory data from clinical laboratories and hospitals with DOH’s internal stakeholders to help them identify disease outbreaks, provide treatment and prevent the spread of disease. Florida SHOTS (State Online Health Tracking System) a free, statewide, centralized online immunization registry sponsored by DOH, helps healthcare professionals and schools to track immunization records. (www.flshots.com) DOH operates the Health Management System (HMS), which is a Web-based clinic practice registration, scheduling, billing and reporting system. It is being used as the platform to launch a new electronic health record over the next year. A web-based e-Lab module is already implemented and eprescribing will be launched next year.

16 Vol. 62, No. 4 2011 Northeast Florida Medicine

The county health departments and the city of Jacksonville are embracing the possibilities associated with the Internet, making it easier for people to access reports and publications; compare data across cities, counties, states and countries and access current and past programs and projects. The DCHD uses its website, www.dchd.net, to inform the Jacksonville community of its health status and DCHD services. Visits to the website have increased considerably since 2008 with an estimated 6,310 visits per day and an average of 800 pages viewed daily as of August 2011. DCHD’s research division, the Institute for Public Health Informatics and Research (IPHIR), had an average of 1,770 hits per month, and approximately 3,050 downloads of Duval County Center for Health Statistics reports, an 18% increase from 2008-09. Public health organizations are now investing resources to make their websites more accessible, user-friendly and informative. DCHD will launch its newly renovated website by the end of 2011. This will simplify access to information on DCHD clinics, health related data, health status updates and emergency alerts. IPHIR will introduce a web-based interactive mapping software to view health-related data. Visitors will be able to create maps and graphs of selected indicators, making comparisons across zip codes, health zones and years. Another important new web-based health resource is www. nefloridacounts.org. This website was launched in May 2011 by a coalition of more than 25 regional partners, led by the Health Planning Council of NE Florida. It includes more than 170 up-to-date health, education and socioeconomic county-level indicators covering seven counties. It also contains more than 1500 promising practices and 250 special data sets. The effective use of the Internet in public health requires an understanding of user needs, characteristics and interests. A website functions as a bidirectional medium through which public health professionals send out health information and receive public feedback. The number of visits to a web page reflect the interests of users and is found to be often influenced by the trends in population health. Public and private sector organizations are utilizing web usage data to modify their websites to meet community needs and influence health behaviors. As we head towards the new age of “e-public health,” we need to work together to increasingly use technology to achieve the public health goals of “Prevent, Promote and Protect.” References Tian H, Brimmer DJ, Lin JM, Tumpey AJ, Reeves WC. 2009. Web Usage Data as a Means of Evaluating Public Health Messaging and Outreach. J Med Internet Res. 2009,11(4):e52.

www . DCMS online . org

Electronic Health Records: Gaining Ground and Improving Quality of Care Background - Benefits that Matter!

The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “Electronic Health Records: Gaining Ground and Improving Quality of Care” authored by Radley Remo, MPH and Robert Harmon, MD, MPH.(see pp. 19-23), which has been approved for 1.0 AMA PRA Category 1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http://www.dcmsonline.org/cme_requirements.aspx).

Faculty/Credentials: Radley Remo, MPH, has been the Coordinator, Center for Health Informatics, Duval County Health Department in Jacksonville, FL since July 2006. He earned his BA degree in health from the University of North Florida in Jacksonville, FL and his

MPH degree from the University of South Florida in Tampa, FL. Robert Harmon, MD, MPH, has served as Director of the Duval County Health Department in Jacksonville, FL since August 2006. He is also an adjunct professor in the School of Public Health at the University of Minnesota. Dr. Harmon received his MD degree from Washington University in St. Louis, MO and his MPH degree from Johns Hopkins University in Baltimore, MD.

Objectives for CME Journal Article 1. Differentiate between the three types of electronic records (EHR, EMR and PHR) 2. Recognize the benefits and challenges of adopting and using an EHR 3. Identify resources to help with EHR adoption and to achieve meaningful use

Date of Release: November 30, 2011 Date Credit Expires: November 30, 2013 Estimated time to complete: 1 hr.

Methods of Physician Participation in the Learning Process

1. Read the “Electronic Health Records: Gaining Ground and Improving Quality of Care” article on pages 19-23 2. Complete the Post Test and Evaluation on page 18 3. Members or non-members must fax the Post Test to DCMS (FAX) 904-353-5848 OR members can also go to www.dcmsonline.org & submit the test online. Non-members must arrange for the CME fee payment before submitting the post test. Call 904-355-6561 x106 or fax.

CME Credit Eligibility

In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the first attempt. DCMS members and non-members have two years to submit the post test and earn CME credit. A certificate of credit/completion will be emailed, faxed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact the DCMS at 355-6561, ext. 103, or llegacy@dcmsonline.org.

Faculty Disclosure Information

Mr. Remo and Dr. Harmon report no significant relationships to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians.The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.

17 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

CME Questions & Answers (Circle Correct Answer) /Free-DCMS Members/$50.00 charge non-members*



Electronic Health Records: Gaining Ground and Improving Quality of Care

Members or non-members - fax Post Test to DCMS (FAX) 904-353-5848, mail to 555 Bishopgate Lane, Jacksonville, FL 32204, OR members can also go to www.dcmsonline.org & submit the test online. *Non-members must arrange for the CME fee payment before submitting the post test. Call 904-355-6561 x106 or fax 904-353-5848 with charge information.

Return by November 30, 2013 1. An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization is called: a. PHR b. ERH c. CPOE d. EHR 2. The capability of different information technology systems and software applications to communicate; to exchange data accurately, effectively and consistently; and to use the information that has been exchanged is: a. Interoperability b. HITECH c. RHIO

5. How many stages of Meaningful Use will there be? a. One b. Two c. Three d. Four 6. Which of the following is not a potential benefit of using an EHR? a. Resource efficiency b. Quality of care improvements c. Cost savings d. Easy to implement

7. What is the most frequent reason for not implementing an EHR?

d. Interchangeably

a. Lack of comfort with technology

3. The electronic movement of health-related information among organizations according to nationally recognized standards is: a. RHIO b. PHR c. HIE d. Interoperability 4. Approximately what percent of clinicians in the U.S. are using a fully operational EHR? a. 5% b. 10% c. 50% d. 100%

b. High cost of EHR c. Too close to retirement d. Don't believe EHRs are beneficial

8. Which of the following are resources for EHR and HIT? a. Office of the National Coordinator b. Agency for Health Care Administration c. Regional Extension Centers d. Centers for Medicaid and Medicare Services

e. All of the above

Evaluation questions & CME Credit Information



(Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree) The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5 Comments:______________________________________________________________________________________ ____________________________________________________________________________________________ Name (Print)___________________________________________Email_____________________________________ Address/City/State/Zip_____________________________________________________________________________ Phone__________________________Fax_____________________DCMS Member (circle)

YES

*Non-Member Charge ($50.00) - See payment options below: (Call 904-355-6561 x106 or Fax information) Credit card: Visa

MasterCard

American Express

Discover

Account #___________________________________Expiration date:_______________________________________ Signature_______________________________________________________________________________________ 18 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Electronic Health Records: Gaining Ground and Improving Quality of Care Radley Remo, MPH and Robert Harmon, MD, MPH Abstract: This article provides a general overview of Health Information Technology (HIT) terminology and Electronic Health Records (EHRs). It provides definitions, reviews the current ambulatory EHR literature, and documents the benefits and challenges of implementing and using an EHR. It describes the current state of HIT and EHR progress in the US, Florida, and locally. Lastly, the article lists resources and references for practices to learn more about HIT and EHRs.

Overview Many specialty and technical areas have their own terminology and HIT is no different. It is important to have a consistent language so that each term is used in the correct context. The Office of the National Coordinator (ONC) for Health Information Technology understood that many HIT terms had multiple and sometime conflicting meanings. Consequently, the ONC issued a contract to the National Alliance for Health IT (NAHIT) to reach a consensus on definitions for the following terms: Electronic Medical Record (EMR), Electronic Health Record (EHR), Personal Health Record (PHR), Health Information Exchange (HIE) and Regional Health Information Organization (RHIO).1 Defining these terms should make it easier to have discussions on developing policies for, and technical standards around, HIT.1, 2

EMR, EHR, PHR: The Differences EMR and EHR have been used interchangeably by clinicians, their staffs, HIT professionals and electronic record vendors. NAHIT has identified a distinct difference between the two concepts, and defines the EMR as: “An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.”1 They define EHR as: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.”1 The key difference between the concepts is the ability to exchange data interoperably. In healthcare, interoperability is the capability of different information technology systems and software applications to communicate; to exchange data accurately, effectively, and consistently; and to use the information that has been exchanged.3 The EHR can exchange Address Correspondence to: Radley Remo, MPH, Center for Health Informatics Coordinator, Duval County Health Department, Jacksonville, FL. Email: Radley_Remo@doh.state.fl.us. 19 Vol. 62, No. 4 2011 Northeast Florida Medicine

information interoperably with external providers, while the EMR is limited to sharing information within its network only. A third concept, Personal Health Record (PHR), is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.1 What distinguishes the PHR from the EHR is the control of information. In a PHR, the individual decides how the record is used and accessed, not the clinician. The NAHIT also defines the following network terms: HIE, HIO, and RHIO. HIE has been used in many instances to describe both the process of health information exchange and the entity overseeing and governing the exchange, therefore, HIE and RHIO are often viewed as synonymous.1 NAHIT defined each term and developed an additional term HIO (Health Information Organization) to help distinguish each meaning. HIE, according to NAHIT, is defined as “The electronic movement of health-related information among organizations according to nationally recognized standards.” It defines RHIO as “A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.” It also describes an HIO as “An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.”1 In simpler terms, the oversight structure (HIO) is the organization that governs the process of sharing information (HIE). The RHIO is a type of HIO that covers a specific region or area such as a state or part of a state.

The adoption of EHRs has been slow, but has increased in recent years.

EHR Prevalence The adoption of EHRs has been slow, but has increased in recent years. The 2010 preliminary estimates from the National Ambulatory Medical Care Survey (NAMCS) show 24.9% of physicians reported having systems that met the criteria of a basic system, while 10.1% met the criteria for a fully functional system. Since 2003 there has been an increase of www . DCMS online . org

14.4 and 7.0 percentage points for physicians having a basic or fully functional system, respectively.4 In the same 2010 survey, 50.7% of U.S. physicians reported using full or partial EHR systems in their office-based practices, compared to 39.4% of Florida physicians. This was significantly lower than the national average. Another national survey conducted in late 2007 and early 2008 showed only 4% of physicians reported having an extensive, fully functional ambulatory EHR system, and 13% report having a basic system.5 The results from these two surveys tell us that the US has made progress, but is still a long way from reaching mass EHR adoption. Many experts believe that EHRs ar the next step in the continued progression of health care that can also strengthen the relationship between patients and clinicians. The data and the timeliness and availability of it will enable clinicians to make better decisions and provide better care.6

Federal Goal/Mandate President Barack Obama stated in 2009 that, “To lower healthcare cost, cut medical errors, and improve care, we’ll computerize the nation’s health record in five years, saving billions of dollars in health care costs and countless lives.” On February 17, 2009, he signed the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was legislation created to stimulate the adoption of EHRs and support technology in the United States. The HITECH Act is part of the American Recovery and Reinvestment Act (ARRA) of 2009, an economic stimulus bill. The HITECH Act stipulates that, beginning in 2011, healthcare providers will be offered financial incentives for demonstrating meaningful use of EHRs. The government is using a “carrot and stick” approach to increase EHR adoption among clinicians. Initially there will be EHR-related financial incentives for clinicians who treat Medicare patients starting in 2011 until 2015. After 2015, penalties may be levied for failing to demonstrate such use. Those clinicians who are not adopting EHR by 2015 will see reductions in their Medicare reimbursements of 1% in 2015, 2% in 2016 and 3% in 2017.7 Meaningful Use (MU) basically defines what hospitals and clinicians must do to reach EHR utilization targets.8 MU is also being introduced as a three-stage process. The first stage focuses on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating for care coordination purposes, implementing some clinical decision support tools, and initiating the reporting of clinical quality measures and public health information.9 In Stage 2, set to take effect in 2013 and 2014, the Centers for Medicare and Medicaid Services (CMS) proposes to expand on the earlier measures to focus on continuous quality improvement at the point of care and the exchange of information in the most structured format possible. Stage 3, 20 Vol. 62, No. 4 2011 Northeast Florida Medicine

for 2015 and beyond, focuses on promoting improvements in quality, safety and efficiency; decision support; patient access to self-management tools; access to comprehensive patient data; and improving population health. CMS will specify the requirements for both Stages 2 and 3 in future regulations.9 In the final Stage 1 regulation, the MU elements were divided into two groups: a set of core objectives that constitute an essential starting point for MU of EHRs and a separate menu of additional important activities from which clinicians will choose several to implement in the first two years.8 The core objectives comprise basic functions that enable EHRs to support improved health care. These functions include the tasks essential to creating any medical record, including patients’ vital signs and demographics, active medications and allergies, up-to-date problem lists of current and active diagnoses, and smoking status.9 In addition to the core elements, the rule creates a second group, a menu of 10 additional tasks from which clinicians can choose any five to implement in 2011–2012. This gives clinicians the latitude to pick their own path toward full EHR implementation and MU. The regulation also specifies the rates at which clinicians will have to use particular functions to be considered meaningful users. These rates of meaningful use will enable significant progress toward improving care but are also achievable by average practices and clinicians in the early years. 9 For example, “patient reminders” is one of the 10 menu set objectives. “Patient reminders” is defined as sending reminders to patients per patent preference for preventive/follow up care. In order to sufficiently meet the objective, more than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period.

Implementing and adopting an EHR will affect everyone involved in the healthcare process.

The Impact Implementing and adopting an EHR will affect everyone involved in the healthcare process. The whole practice, especially the clinicians, office staff and even the patients, will be impacted in many ways. Initially, the learning curve for use of EHRs is expected to be fairly steep. When clinicians first begin using EHRs for order entry and note authoring, it will take them longer to see patients. The decrease in patients seen may be as much as 30% at first, and facilities must be prepared for this.10 However, time saved by directly entering orders and by not having to search for information will soon begin to reverse the productivity impact. This impact can be reduced further if the facility provides adequate support and training for clinicians and staff. Eventually, clinicians will be able to document both www . DCMS online . org

more thoroughly and more rapidly on standardized documentation templates than previously possible by handwriting.10 One study showed that employees of the clinic perceived few changes in their work after the implementation of the EHR system, except for increased dependency on computers and a small increase in perceived workload. The work analysis showed a dramatic increase in the amount of time spent on computers by the various job categories. The EHR implementation did not change the amount of time spent by physicians with patients. On the other hand, the work of clinical and office staff changed significantly and included decreases in time spent handling charts, transcription and other clerical tasks. 11 Current studies have derived the following conclusions regarding how the physician-patient relation is affected by the use of EHRs12: • Generally, patients are equally satisfied with physicians who use EHRs and those who use paper charts13; how ever, some patients feel confused by certain behaviors, such as the physician looking at the computer monitor without explanation.14 • How physicians use EHRs during an office visit (and how much time they spend typing on the computer versus talking with the patient) is influenced by their communication style and perception of their professional role in relation to the patient.15 • The presence of the computer monitor improves the patient-centered behaviors of physicians who exhibited good behaviors with paper charts; however, the computer monitor worsens the patient-centered behaviors of physi cians who had poor interpersonal skills before the intro duction of EHRs.16 The clinician and his/her staff will need to be aware of these issues and effectively plan to minimize the impact on the patients and the practice.

Potential EHR Benefits There are many potential benefits for adopting and using an EHR in a small practice.17-20 The benefits can be grouped into the following categories: resource (clinician and staff) efficiency, quality of care improvements, and financial performance and cost savings. Efficiencies can be seen from a reduction of staff’s time spent finding and pulling paper charts, using more medical transcription, or reducing unnecessary health care services such as duplicate diagnostic tests. Quality of care improvements realized from an EHR can be identifying and preventing harmful drug interactions or possible allergic reactions to prescribed medicines or helping physicians manage patients with complex chronic conditions. 21 Vol. 62, No. 4 2011 Northeast Florida Medicine

An additional way an EHR can improve quality of care is by reminding clinicians about discussing appropriate preventive care measures with their patients. Several studies show that practices that implement an EHR have better financial performance and cost savings.21-23 One study shows a positive return on investment to a healthcare organization in an ambulatory setting.21 Another study reviewed 14 solo or small group practices which adopted EHRs. The result showed that the average practice paid for its EHR in 2.5 years and profited handsomely after that.22 A recent report by the Medical Group Management Association (MGMA) also concluded that EHRs over time will help a practice’s bottom line.23

Hesitations in Implementing EHRs With the many benefits of EHR, there are also many barriers and challenges, particularly among small ambulatory practices.24-26 The major barriers can be categorized into financial, technological, organizational and consumers.26 The high cost of implementation is one of the most frequent barriers to implementing an EHR.22-25 Even large organizations such as hospitals cite cost as a major barrier.27 At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing an EHR will cost more than $32,000 per physician, and maintenance may be about $1,200 per month. Vendor costs only account for 60-80% of these expenditures. Other cost such as the on-going maintenance and training make EHR adoption prohibitive for some organizations.24,26 Many small practices would not be able to afford these initial and on-going costs, unless they plan and save for the planned cost. Technology barriers consist of the clinician’s comfort with computers, navigation of the EHR marketplace and inadequate technical support.26 Many seasoned clinicians are not comfortable with computers and therefore, are quite resistant to using an EHR. Another barrier is technology overload. There are so many EHR vendors and products on the market that the clinician could spend a large amount of time researching and identifying the best EHR for his/her practice. Lastly, is technical support. There are not enough highly skilled health IT experts to support clinicians in the adoption and MU of EHRs.28 Implementing an EHR will have major impacts on an organization. Moving from paper to paperless will probably disrupt the clinic’s workflow and will slow down the practice. In some temporary situations, practices will be using both paper and paperless concurrently and lose any efficiency gained from going paperless. Acceptance and privacy rank as the top consumer barriers. The need for patients to become more computer literate and to have Internet access can be potential barriers. Concerns for privacy such as how information accessed, disseminated and stored must also be fully addressed. The federal government has passed legislation that addresses many of these challenges and will help clinicians adopt EHRs. www . DCMS online . org

HIT and EHR Landscape In Florida there is a large volume of HIT activity. The Agency for Healthcare Administration (AHCA) is coordinating the statewide HIE. Recently, AHCA also provided financial support for the development of RHIOs. To date there are ten RHIOs in Florida, with three being active in exchanging data. AHCA also coordinates the HIT policy issues affecting the state. The Health Information Exchange Coordinating Committee (HIECC) provides guidance to AHCA as it develops and implements specific programs for creating a statewide health information exchange network, adopting EHR systems, and ensuring the privacy and security of health information.29 AHCA is also in charge of designing and implementing the Florida Medicaid Electronic Health Record (EHR) Incentive Program. This program started in September 2011. 30 AHCA’s sister organization, the Florida Department of Health (FDOH), is also working on HIT projects. It is in the midst of developing and launching a statewide EHR for its 67 county health departments. The EHR program is called Healthcare Management Systems (HMS) and is a homegrown product that will utilize some commercial products to enhance its modules. The plan is to certify HMS as a certified EHR by the end of 2012. The FDOH is also considered a leading agency for e-public health. Its Bureau of Epidemiology recently received the 2011 HIMSS Public Health Davies Award for its Electronic Surveillance System for the Early Notification of Community-based Epidemics, Florida, or ESSENCE-FL project.31 FDOH has also implemented a statewide immunization registry and data exchange called Florida SHOTS.32 In addition to state government activities, the federal government has also funded four Regional Extension Centers (RECs) in Florida.33 The purpose of the RECs is to provide education, outreach, and technical assistance to help clinicians in their geographic service areas to select, successfully implement, and meaningfully use certified EHRs to improve the quality and value of health care. Each of the RECs covers specific counties and all target small primary care practices and Federally Qualified Health Centers (FQHC).

receives and shares EHR data on the uninsured and Medicaid population. The purpose of the JHIN is to help practices and hospitals manage the care of these patients more effectively by sharing data and reducing costs NEFHIC is a consortium of eleven community partners that promotes and helps to realize the use of electronic health information to improve medical care and improve public health. Its vision is that the Northeast Florida Community can appropriately access, utilize and benefit from interoperable and secure electronic health information.36

Resources For help with the adoption of an EHR or achieving MU, the Regional Extension Center (REC) is a good place to start. It doesn’t matter if you have an EHR or not. The REC can help clinicians and their practices get to meaningful use and receive CMS incentive payments. If your practice is located in Northeast Florida, the Advancement of Health Information Technology (AHIT) REC is the REC that covers the area. The links below provides additional information on HIT, EHR, and where need to find a local Regional Extension Center.

• • • •

ONCHIT—-http://healthit.hhs.gov/portal/server.pt/ community/healthit_hhs_gov__home/1204 CMS EHR Incentive Program—http://www.cms.gov/ ehrincentiveprograms/ AHCA—http://ahca.myflorida.com/medicaid/ehr/ about_ehr.shtml AHIT REC—http://www.chcalliance.org/Services/ RegionalExtensionCenter.aspx

References 1.

Other statewide organizations are also supporting HIT activities. The Florida Medical Association (FMA) has presented a number of EHR workshops around nine cities throughout Florida.34 The Florida Academy of Family Physicians (FAFP) has implemented the EHR NOW! program and continues to provide its members links and resources in navigating EHR implementation.35

Defining Key Health Information Technology Terms. The National Alliance on Health Information Technology. Apr 2008 http://healthit.hhs.gov/portal/server.pt/gateway/PT ARGS_0_10741_848133_0_0_18/10_2_hit_terms.pdf. Accessed August 15, 2011.

Electronic Medical Record vs. Electronic Health Record: Yes, there is a difference. HIMSS Analytic White Paper. Jan 2006. http://www.himssanalytics.org/docs/wp_emr_ehr.pdf Accessed August 15, 2011.

Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601).

Northeast Florida has a number of coalitions that evolve around HIT. The Northeast Florida Health Information Exchange (NEFHIE) and the Northeast Florida Health Informatics Consortium (NEFHIC) are the two most active. NEFHIE, formerly JaxCare, manages the Jacksonville Health Information Network (JHIN). The JHIN is the local HIE that

Hsiao CJ, Hing E, Socey TC, Cai B. Electronic Medical Records/ Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates. National Center for Health Statistics Health E-stat. December 2010.

DesRoches CM, Campbell EG, Rao SR, et al. Electronic Health Records in Ambulatory Care – A National Survey of Physicians. N Engl J Med 2008;359-50-60.

22 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Centers for Medicare and Medicaid Services web page. https:// www.cms.gov/EHealthRecords. Accessed August 15, 2011.

Centers for Medicare & Medicaid Services. The official web-site for the Medicare and Medicaid EHR Incentive Programs.Available from: http://www.cms.gov/ EHRIncentivePrograms/01_Overview.asp#TopOfPage. Accessed August 15, 201.

Blumenthal D, Tavenner M. The “Meaningful Use” regulation for electronic health records. N Engl J Med 2010;363:(6)5014. http://healthpolicyandreform.nejm.org/?p=3732 . Accessed August 31, 2011.

American Hospital Association. HIT Incentive Payment Program:Definition of “Meaningful Use”. http://www.aha.org/ aha/content/2010/pdf/10-ib-def-meaning-use.pdf . Accessed August 31, 2011.

10. U.S Department of Health, Indian Health Services web page http://www.ihs.gov/CIO/EHR/index.cfm?module=faq#20. Accessed August 31, 2011. 11. Carayon P, Smith P, Hundt AS, et al. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behavior & Information Technology 2009;28:5-20. 12. Ventres W, Shah A. How do EHRs affect the physician-patient relationship? Am Fam Physician. 2007 May 1:75(9):1385-1390. http://www.aafp.org/afp/2007/0501/p1385.html. Accessed August 31, 2011. 13. Solomon GL, Dechter M. Are patients pleased with computer use in the examination room? J Fam Pract. 1995;41:241-4. 14. Als AB. The desk-top computer as a magic box: patterns of behaviour connected with the desk-top computer; GPs’ and patients’ perceptions. Fam Pract. 1997;14:17–23. 15. Ventres W, Kooienga S, Marlin R, et al.. Clinician style and examination room computers: a video ethnography. Fam Med. 2005;37:276-81.

25. Menachemi N. Barriers to ambulatory EHR: who are “imminent adopters” and how do they differ from other physicians? Informatics in Primary Care. 2006;14:102-8. 26. DOQ-IT EHR Adoption: A Barrier Analysis. http://healthit. ahrq.gov/portal/server.pt?CommunityID= 666&spaceID=399 &parentname=&control=SetCommunity&parentid=&PageID =0&space=CommunityPage&in_tx_query=ehr+adoption+bar riers&Submit.x=0&Submit.y=0. Accessed August 15, 2011. 27. Jha AK, DesRoche CM, Campbell EG, et al. Use of Electronic Health Records in U.S. Hosptials. N Engl J Med. 2009;360(16):1628-38. 28. ONCHIT Health IT Workforce Development Program website.http://healthit.hhs.gov/portal/ser ver. pt?open=512&objID=1432&mode=2. Accessed August 31, 2011. 29. AHCA FHIN website. http://168.82.75.17/content/ committeesAndCouncils/. Accessed August 30, 2011 30. AHCA website. http://ahca.myflorida.com/medicaid/ehr/. Accessed August 30, 2011. 31. HIMSS Conference Chicago 2011.http://www. healthdatamanagement.com/news/himss-davies-awardpublic-health-43061-1.html. Accessed August 30, 2011. 32. Florida SHOTS; http://www.flshots.com/. Accessed August 30, 2011. 33. AHCA website: http://ahca.myflorida.com/medicaid/ehr/ regional_extension_centers.shtml. Accessed October 5, 2011. 34. Florida Medical Association;http://flmedical.org/ehr/. Accessed August 30, 2011. 35. Florida Academy of Family Physicians; http://www.fafp.org/. Accessed August 30, 2011. 36. NEFHIC; http://www.nefhic.org/. Accessed August 31, 2011.

16. Frankel R, Altschuler A, George S, et al. Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20:677-82.

DCMS Alliance Presents Donation to We Care

17. Sidorov J. It ain’t necessarily so: The EHR and the unlikely prospect of reducing health care costs. Health Affairs. 2006;25(4):1079-85.

(Photo L to R) Dr. Sue Nussbaum, Executive Director of We Care, accepts a $1,000 donation from Mrs. Dena Pulley, DCMS Alliance President, to be used for Caring Awards scholarships. The 2011 Caring Award reception was November 10. We Care is "a voluntary coalition of healthcare professionals, clerical personnel and local church groups that provide primary and specialty care to the uninsured, homeless and the medically underserved people of Jacksonville."

18. Congressional Budget Office. 2008. Evidence on the costs and benefits of health information technology. Available at www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf. Accessed August 31, 2011. 19. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and cost. Health Affairs. 2005;24(5):1103-16. 20. Buntin MB, Burke M, Hoaglin MC, Blumentahl D. The benefits of health information technology: A review of the recent literature shows predominantly positive results. Health Affairs. 2011;30(3):464-71. 21. Wang SJ, Middleton B, Prosser LA, et al. A Cost-Benefit Analysis of Electronic Medical Records in Primary Care. American Journal of Medicine. 2003;114:397-403. 22. Miller RH, West C, Brown TM,.et al. The Value Of Electronic Health Records In Solo Or Small Group Practices. Health Affairs. 2005;24(5):1127-37. 23. Electronic Health Records Impacts on Revenue, Costs and Staffing: 2010 Report Based on 2009 Data. http://www.mgma.com/press/ default.aspx?id=39824. Accessed August 15, 2011. 24. Fleming NS, Becker ER, Culler S, et al. Financial performance of primary care physician practices prior to electronic health record implementation. Proceedings. 2009;22(2):112-18. 23 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Effective Communication and Marketing Strategies for Today's Busy Physicians A.J. Beson, President/CEO and Vanessa Wells, Editor, Beson 4 Media Group

Introduction - A Good Physician Listens I once knew a surgeon who gave this advice to incoming residents: “Don’t be a physician. Just listen.” The premise was that the best doctors are also the best listeners, and that one of the best ways to help patients is to take the time to listen to them. When it came time to write about how the internet can help physicians better market their practice, these words echoed in my head. As healthcare marketers in 2011, the best way to effectively reach our customers is by opening channels of communication and hearing what these customers have to say. Both the healthcare and the marketing industries have experienced unprecedented shifts in the last few years. In one aspect, these changes have created better informed healthcare consumers who feel that they have more ownership over their individual health and the health of their families. The other side of the coin demonstrates healthcare consumers are overwhelmed by the amount of misinformation out there and eager to find a reputable and trusted source. It is now the responsibility of individual physicians to market themselves and serve as that reliable resource. The internet turned 20-years-old this year. The first website was launched August 6, 1991. According to the leading digital blog, Ecoultancy, there were more than 640 million people on Facebook, 175 million Twitter users and over 100 million LinkedIn profiles as of August 2011. It’s no longer questioned that technology has forever changed the way we live and the way we do business. The internet has changed who we are. We need immediate access to everything. That includes immediate access to our physicians. Your patients don’t want you to be on the internet – they require you to be on the internet. The consumer is now in control.

Communicating Through the Noise There is plenty of digital noise out there. How can you communicate with your patients through the noise? How can you differentiate your practice? How can your existing patients gain immediate access to you? How can new patients learn enough about you to pick up the phone and call to schedule an appointment? Address Correspondence to: A.J. Beson, President and CEO of Beson4 Media Group, 13500 Sutton Park Drive South, Suite 105, Jacksonville, Florida, 32224 & (904) 992-9945, Email: aj@ beson4.com. 24 Vol. 62, No. 4 2011 Northeast Florida Medicine

Implementing any type of marketing effort can be daunting. Implementing an effective web marketing campaign can be overwhelming. Combine that with the fact that many physicians already have limited resources and even less time it is no wonder so many doctors are hesitant to begin such an endeavor. While online marketing does require an additional investment of money and time, the proper strategy can mean more new patients and better communication with existing patients. That’s why it is so critical to make the right decisions in the beginning. Take your time. Talk to experts. Interview marketing firms, follow blogs, ask your grandchildren and most importantly, ask your patients. The site, www.surveymonkey. com is a free resource where you can create quick surveys. Send a survey to all of your patients and ask them where they spend their time online, ask them if they’d like updates via Facebook, if they would subscribe to an enewsletter or

If you make smart, well-informed choices, you will have success reaching existing and new patients via the web. if they’d follow a blog. Collect the results and consult an expert. Spend time evaluating your options and take your time making a decision. Many physicians decide to slowly integrate into web marketing. If you do this, just make sure as you add more and more outlets, you maintain a cohesive identity. If you make smart, well-informed choices, you will have success reaching existing and new patients via the web. At the end of this article there is a list of marketing industry resources that will provide further information and insight.

Beginning a Campaign There are many facets of an effective web marketing campaign. Where do you begin? Step one is developing an integrated plan that you can execute and measure. You need a clear strategy and defined goals. Figure out if someone in your company will be responsible for executing that strategy and attaining those goals or if you will be consulting an outside resource. Monitor the competition and monitor your audience. Be fluid in your strategy in case you need to change or adjust something. Basic components would likely include a website which has a blog you can update frequently, an e-newsletter campaign, Facebook, Twitter, LinkedIn and YouTube. For instance, an orthopedic surgeon’s website and blog would be comprised of useful orthopedic content pertinent www . DCMS online . org

to patients and referring physicians. The doctor might also send a monthly e-newsletter detailing timely and topical tips on sports injuries, bone health and ways to avoid slips and falls. They would post fun and interactive content on Facebook such as fitness quizzes or photos from a recent open house. The same doctor would utilize Twitter as a way to disseminate information quickly, “Don’t 4get…free concussion prevention class @ the clinic this weekend. Be sure to RSVP to …” They would use LinkedIn to connect with professional associations, specialty groups and others in the healthcare field and as a recruitment tool. On YouTube, they would post informative videos such as “How to Prepare for a Marathon” or a tutorial that prepares patients for a knee replacement. Everything would link back to the orthopedic surgeon’s website.

Branding Yourself and Defining Your Audience Your website needs to define your practice and completely represent your brand; consider it your practice’s online identity. You need to define your audience as well. Who are they and what are they looking for? Are you a specialist who relies on referrals? Then your website needs concise information about the latest innovations and news in your field that’s quick and easy for doctors to access. Are you a pediatrician who needs to reach busy moms? Then offer valuable parenting tips. Maybe you rely on both patients and doctors for referrals. Then consider separate sections dedicated to two different audiences. Once you’ve determined who you need to reach, you can get started on how to reach them. From an optimization standpoint, you need fresh content. You should update your website at least once a month. If you plan to update weekly or even daily, it might make sense to look into a content management system so you’re not calling the web company every five minutes for changes. When writing text for your site, consult a search engine optimization (SEO) expert. When it comes to SEO, forget the fluff in the first 100 words. Stay away from words and phrases like “caring, loving, compassionate, friendly staff” and “patient care.” Determine which key words and phrases your audience is searching for, and include them in the first 100 words. If you are an oncologist, key words may be “cancer”, “lumps” and “chemo”. If you are an allergist, key phrases may be “runny nose”, “itching eyes” and “rash”. People looking for an orthopedic surgeon may type in “torn rotator cuff”, “hip replacement” or “back pain”. Include video on your site. You can buy a fairly inexpensive pocket video camera like the Kodak Zi8 and download inexpensive editing software so you can edit and upload video to your site. Great video content includes doctor bios, patient testimonials and a virtual tour of your office. You’ll want to upload video to your actual site as well as your YouTube channel. Make sure the design elements of your website communicate the tone of your brand. Think of how you want your patients 25 Vol. 62, No. 4 2011 Northeast Florida Medicine

to feel when they walk into your office. Make sure the design, photos, videos and copy on your website communicate that same feeling. If you are a pediatrician, bright, bold colors and photos of the playroom at your office are appropriate. If you are an oncologist who wants your waiting room to be reminiscent of a spa, use cool, calming hues and softer tones. Once you’ve created a website and are uploading great, fresh content on a regular basis, make sure you have an integrated, consistent brand across all online platforms. When communicating via social media or another online mode, take every opportunity to link back to your site.

Using Email Effectively An e-newsletter campaign is a great way to stay in front of your patients on a monthly basis. When collecting patient information, be sure to have a place for an email address. Start by sending quarterly or monthly e-newsletters. Send quick and easy tips and facts about your specialty and the practice itself. E-newsletters are great for announcing new staff members, office locations or any other pertinent information about your practice. Keep your e-newsletters short and add lots of photos and/or video. Stick to catchy headlines that are only a few words long. Be aware of the words you

E-newsletters are great for announcing new staff members, office locations or any other pertinent information about your practice. use and consider what may or may not hit a spam filter. For instance, “Pink Ribbon 5K” might be a better title than “Breast Cancer Walk”. Include links to surveys, discounts and offers and contests in your e-newsletters. People like to click on pictures, so make sure every photo links through to your website for more information.

Winning Fans and Influencing Followers When posting on Facebook, the most important thing to consider is interactivity. When businesses set up a Facebook page, it needs to be a fan page. Friend pages are reserved for individuals. Once your fan page is created, you can invite people to “like” your page. While everyone would love a ton of “likes” on their page, “likes” don’t really matter unless your viewers are engaged. “Likes,” in fact, are beginning to matter less as Facebook changes the way it does things. The word of the day is “sharing.” It’s important to post things viewers are likely to share such as photos from a recent event or a video of an inspiring patient story. When it comes to your tone on Facebook, opt for a conversational approach, ask questions and be original. Understand your audience’s interest and cater to those interests. Be upbeat and use familiar language. www . DCMS online . org

Developing Real-time Results

Avoid technical jargon and be approachable. Ask for input. Perhaps most importantly, understand the power of the word, “You.” Sometimes directly addressing your audience via social media or even through an e-newsletter is the quickest way to engage them. “Seven Steps to a Slimmer You” is better than “Weight Loss Tips”. Asking fans their opinion goes further than telling them yours. Twitter is a two-way street. It’s a place to connect with potential patients but it’s also a place to get quick insight about your industry. Follow your favorite sources of information on Twitter for an easy, accessible way to keep up-to-date. LinkedIn provides a great opportunity to network with referring physicians and industry organizations. It’s a great place to recruit for your practice. While LinkedIn may not be something you use daily, keep it updated and check in from time-to-time.

Utilizing Search Engines While search engine optimization plays a huge role in establishing a cohesive and effective online marketing strategy, keep in mind other ways search engines like Google and YouTube can help your brand. YouTube is the second largest search engine in the world next to Google. Have a branded YouTube channel and post all of your videos there. YouTube is great for sharing. Patients can email videos or post them on their own Facebook page. People will also search medical conditions and procedures via YouTube, so you should be ready with the information they are looking for. Again, keep your audience in mind, and don’t be afraid to create something lighthearted and fun if that’s what is going to resonate with viewers. Google is your friend. Sign-up for Google alerts. Google alerts are email updates of the latest relevant Google results (web, news, etc.) based on your choice. For Google alerts, create alerts on anything pertinent to your brand including the name of your practice and the name of each physician in your practice. That way, you will get a daily email letting you know if there is any “talk” about you or your practice on the web. Be sure to update Google maps and places as well. That’s the first place potential patients tend to look when they are trying to find you. For more information, visit http://www. google.com/alerts and www.google.com/placesforbusiness. 26 Vol. 62, No. 4 2011 Northeast Florida Medicine

Developing a reporting structure and analyzing data are both critical in executing an effective online marketing strategy. There are plenty of inexpensive reporting mechanisms out there, but you may want to consult an expert to make sure you are collecting the data specific to your goals. Google analytics and Facebook insights are two great places to start. It’s fairly easy and straightforward to set up a Google analytics account. Check out Google Analytics Getting Started Guide (http:// www.google.com/analytics/) for more information. Once your account is set up, you can run reports and collect data on such things as number of visits, pageviews, new visitors and average time viewers spent on your site. Facebook insights are automatically generated when you create a fan page and will show you such things as page likes, post feedback and weekly activity. For more information, visit https://www. facebook.com/help/search/?q=insights.

Conclusion Whether it is you, a fulltime staff member, an agency or consulting firm or all of the above getting your message out, make sure your voice is engaged, relevant, receptive and accessible. This will truly help you connect with your patients where they are. Communicate through as many channels as your patients are plugged into. This may include your website, e-newsletter, Facebook, Twitter, LinkedIn and YouTube. Be ready to change strategy when you discover something is or isn’t resonating with your audience. Do more of what works and eliminate what doesn’t. You want your patients interacting with you. You want an easy and natural flow of two way communication between your patients and your brand. Chances are, if your customers aren’t talking, they probably aren’t listening either. Online Resources Below are industry websites that provide pertinent insight into online marketing. • www.beson4.com: local healthcare marketing insight • http://www.google.com/alerts: Google alerts • http://www.google.com/analytics/: Google analytics • www.google.com/placesforbusiness: Google places • https://www.facebook.com/help/search/?q=insights: Facebook insights • www.mashable.com: marketing and social media insight • www.fastcompany.com: technology, marketing and design insight • www.helpareporter.com: sign up to receive daily emails of journalist queries • www.surveymonkey.com: create surveys to email patients and referring physicians • http://ebennett.org: hospitals and social media insight • general business and marketing tips • www.sethgodin.com: general business and marketing tips www . DCMS online . org

Social Networking: Who Are Your "Friends"? Daniel Kantor, MD Abstract: Whether you are ready or not, social media has become an integral part of the way patients expect to interact with their physicians. For the harried physician, engaging in social media may seem daunting at first. But the benefits of developing a comprehensive social medial campaign outweigh any potential disadvantages. Social media can be an effective way of recruiting new patients and is crucial in the growth of a medical practice. Instead of dismissing the importance of social media as simply a teenage fad, physicians should look carefully at how this user-friendly medium can be harnessed for the ultimate benefit.

Introduction Tweets? Facebook? These dizzying new words in our dictionary have become central to the way our patients communicate with each other, and with us, their physicians. Social Media has not only changed the way that people communicate with each other or the way that consumers identify with their favorite brands, but also the way that patients seek contact with their physicians. Many of us are approached by patient-oriented sites to volunteer our time and answer patient questions, while other physicians have created their own interactive websites and Facebook pages. The fundamental principle behind social media is that it is a way to connect “friends” to each other. Many (if not most) of these “friends” are virtual only, and there have never been face-to-face human interactions. While the idea of connecting with friends, especially with patients (or potential patients) may seem foreign to many physicians, the fact that prior interaction is unneeded, can lend itself to a model of virtual interaction among physicians and the general public. Social media allows physicians access to thousands of potential patients, and may allow the physicians the ability to control the tone of the discussion, a well as the content. There are various ways of structuring the interactive dynamic. Some physicians choose to disseminate information in a unidirectional manner (simply using the Internet as a publisher, such as disseminating an e-newsletter or updating content on a website), while others choose to create a truly interactive experience. The choice of which method of interaction is appropriate depends on your practice type, how much time you are willing to invest in a Web presence and your individual goals. Importantly, your level of computer savviness is fairly unimportant, as the social media tools available are fairly user friendly and do not require advanced computer knowledge. Tackling an EMR (Electronic Medical Record) makes having a social media presence seem like introductory Biology.

Address Correspondence to: Daniel Kantor, MD, Medical Director of Neurologique and the President of the Florida Society of Neurology in Jacksonville, FL. Visit: www.neurologique.org.

27 Vol. 62, No. 4 2011 Northeast Florida Medicine

Facebook and Patient “Friends” Facebook, currently the most popular social media site with over 300 million users, uses the term “friends” to describe the connection between individuals. While some physicians use Facebook to connect with their real-life friends and family, it is important to separate these connections from the public. You should be cognizant of the privacy options (fairly straightforward) available to you. Remember that if your profile is visible to others, your patients will have access to it as well.

Brief Guide to Facebook Terms

While Facebook is currently the most popular social media website, it also contains the most number of novel terms. This is a brief glossary of the most important terms for a novice: • • • • • • • • • • • • •

Fan – A Facebook user that follows the content of a Page. This person does not necessarily need to be your Friend of your individual Facebook account. Friends – The foundation of social media is that you are connecting with others (but this doesn’t need to be socially). Your Friends are theses connections with others. Friend Request – This is usually how Friends connect with each other – you can accept, deny or ignore this Friend Request. The person making the request only sees when you accept their request but they may also notice when you deny or ignore it, since you will not be connected (but they do not get an announcement stating “denied”). Group – A collection of Facebook users who post comments to each other. Group updates may be received as emails and/ or in the Notifications section. Many physician practices choose to create Pages rather than Groups, since updates on Pages appear on an individual’s Wall, while an individual needs to visit the Group (or read Notifications or emails) in order to see Status updates. Like – A way of letting others know that you appreciate something that others have posted. The goal of many Face book users is to collect as many Likes as possible to show others that their content is popular. Individuals Like your Page in order to follow your Status updates. This is often indicated by a thumb up image. Member – A participant in a Group. Messages – A way for Facebook users to send private mes sages to each other. News Feed -- The place on Facebook where your individual content will be posted and visible to others Notifications – A list of changes that your Friends have made to the profile of their accounts, including initially accepting your Friend request. Page – As opposed to an individual Facebook account, a Page allows you a more clearly professional way to disseminate information that others follow on their Walls. Profile – The individual Facebook account. You control the user data that others see. Profiles have different level of privacy, including being Public and visible to all. Status – The individual pieces of content that you create and that Friends view on their Walls. Wall – The place on Facebook where your Page content will be posted and visible to others

www . DCMS online . org

One way of avoiding this is to put the minimum amount of information on your profile and to set your privacy controls to the maximum. An even more private method is to keep yourself “hidden” so that only your true friends who know that you are on Facebook can become part of your social network. If your patients discover you on Facebook, then they may want to befriend you and you will be forced to either accept their friendship or to deny or ignore their requests. Therefore, it may be desirable to use Facebook only as a professional tool and to treat “friendships” as connections with the public. People on Facebook tend to befriend (and collect) others. This may be used to your advantage by growing your audience and potential patient base. Of course, many physicians will choose to have their own social Facebook presence and will not want to avoid Facebook simply because their patients use it also. A way to get around this is to select strict privacy settings and to create a separate Facebook page for your practice. Facebook is the social media outlet with the largest number of users. Initially Facebook allowed individual users to connect with each other, but it has progressed to Fan Pages. A doctor’s practice could open a Facebook Fan Page that allows the practice to communicate with the public. Once patients join the Fan Page, their ‘friends” could be encouraged to join as well, and then their friends would join – the viral idea of social media would mean that others would join. The key to keeping the Public engaged is to update content frequently and to make it relevant to the “viewing audience.” Interaction between the users and the physician (or physician representative) is crucial. Facebook users are accustomed to immediate and timely responses, and this means that allowing others to comment on your Facebook Wall (the page where you are expressing your ideas/thoughts) would be seen as inviting questions and would mean that you are giving up complete control of the content because some of these comments may not be entirely appropriate. You can easily adjust the Facebook settings and not allow such bidirectional communication.

Pediatric Perspective

As opposed to much of Medicine where Pediatrics may feel left out, social media is one glaring exception. While you may need to devise ways to have adults Friend you on Facebook and other social media outlets, teens and twenty year-olds have been brought up in a world of virtual friendships and online information seeking. This does, however, raise additional concerns. While there may be concerns about doctors giving any sort of general advice online, this can be especially sensitive when minors misinterpret general education for actual medical advice. Furthermore, answering questions posed by minors (without parental consent or even knowledge) may be seen as inappropriate by both the physician and the parents. It is difficult to simply state “you must be 18 or older” since there is no way of assuring that people on the internet are whom they claim to be. While these issues should be taken into account, they should not dissuade you from entering the Social Media Age as the benefits may outweigh the risks. Consulting an attorney knowledgeable in this area is advised.

28 Vol. 62, No. 4 2011 Northeast Florida Medicine

How to Open a Facebook Page

The way Facebook is structured, is that each individual has a unique account with a “Wall” where the user or the user’s “Friends” can post “Status Updates” about what they are thinking, doing or other items of interest. For many physicians, even once privacy concerns are allayed by the user’s ability to define who sees their posts (certain Friends, all Friends, the entire Public), the social nature of Facebook, including the, sometimes, frivolous postings may not be appropriate. This is where Facebook Pages become useful. A Fan Page allows a business, organization, product, brand etc. to promote itself and to invite comment by others regarding various topics. For example, a physician may want to (on a regular basis) remind Facebook Fans that new patients are being accepted, along with details on how to make an appointment. Other physicians may want to post updates pertinent to their field of interest (and even more importantly, what interests their patients) For example, they could post, “New research trial confirms the need for good sugar control in people with diabetes.” This endocrinologist could even go further and post: “Is your diabetes under good control? New research trial confirms the need for good sugar control in people with diabetes. Call (904)555-5555 to make an appointment today and visit www.drsmith.com for more updates.”

How to Create a Facebook Page • Creating a Facebook account and connecting with Friends. • Creating a Facebook Page and inviting the Friends to sign up for the Page – those invited will receive a request that states: Dr. Smith’s Clinic Page You have been invited by Dr. John Smith (Jacksonville, FL). Do you like this? By having your Friends like your Page, you will be accumulating followers and these people will be reading your postings whenever they log in to Facebook. This is valuable because you will assemble a captive audience for the information that you are trying to disseminate whether it is advertising for your practice or purely educational. Your goal should be to have as many people as possible Like your Page because this will increase your audience. This can happen by you directly inviting Friends and by having them spread the word to others and invite them to Like your page as well.

Step-by-step guide: 1. Go to www.facebook.com. 2. Sign up for Facebook and create an account. 3. To create a Facebook page, go to www.facebook.com/ page. 4. Choose a category for your business (it could be your practice, brand etc.). 5. Invite “friends” to join your Facebook page. 6. To find people that you may know, simply type their name in the Search bar on the top of the Facebook screen. 7. When you link to another person’s “Wall”, click on “Add Friend.” 8. Type your postings on your “Wall” where it says “Write something”… and click on “Share”. www . DCMS online . org

LinkedIn for Colleagues Social media outlets are not only appropriate for interactions with the public, but with other health care professionals as well. Generally, sites such as LinkedIn are more appropriate for physician-physician interaction than sites such as Facebook, Myspace or Google+ (Google Plus). LinkedIn encourages users to update their online CVs and to form networks based on employment, education and interests. This means that you may use LinkedIn to update your professional profile (publications, presentations, employment), while you may use other avenues to create and disseminate novel content.

Twitter and Tweets Contrary to its name, Twitter has nothing to do with ornithology. Instead, Twitter allows users to publish 140 characters of content that can be “followed” by an unlimited number of people. These content updates are termed “tweets” and are often read through mobile devices. An example of an appropriate tweet would be, “Dr. Smith is now accepting new patients at her new location – 1345 New Wales St., Jacksonville FL 32204.” This timely brief reminder serves as an advertisement for a new location and could potentially increase patient traffic. Other physicians use Twitter to also update the public (current and prospective patients) on new developments in their field of interest. For example, a tweet could read: “Nuedexta receives FDA approval as the first and only treatment for pseudobulbar affect – to learn more visit: www.drsmith. com.” The advantages of Twitter are that you only need to write a short blurb and that you can control the message, while the disadvantages are that you are constrained in terms of space and in reach.

Creating Online Content While you may need help from a web savvy employee, friend or perhaps offspring to initially set up your social media framework, you need to decide who will be responsible for actually creating and updating your content. You have three main choices in deciding who is responsible for updating your social media presence:

1. You – The advantage of doing this on your own, is that you completely control your online presence just as you are responsible for how you interact with others in the real world. The disadvantage is that it is time consuming, but it does not need to be too much of a burden if your social media setup is designed well. Twitter is especially useful in this regard because of the character (140) limitation. 2. An employee – The advantage of having someone else invest the time is obvious, but the disadvantage of en couraging social media use during the workday is obvi ous. Social media use and Internet surfing can severely limit the productivity of your staff. 3. An outside vendor – The advantage is this frees up some of your own time, but beware of the disadvantage of still having to let the outside vendor know what content you want updated. Social media users are used to timely updates and using a third party can significantly delay this.

While it may make sense for you to make your own updates, it is important to take a step back at the beginning and to devise an appropriate and comprehensive social media plan. You will probably need to engage others for help with this, but you may not need to go to the expense of a formal consultant or company. A partner’s children in their teens or twenties may suffice (and even be more desirable as they understand your local concerns). With website design you probably want to hire a professional, but since social media updates need to be timely and relevant, it is best to make these updates on your own.

Disseminating Content The whole idea of social media is to create an audience for your content. While you can invite individual users, it is important to grow your audience by creating value. Value is defined as information that your intended audience will be interested in and want to share with others. This will increase your viewership and potentially your patient base. You should first start with text-based information; timely updates on advances in your field and practical suggestions and health tips. It is important to keep this information general and not to give individual medical advice. This becomes even

Practical Suggestions to Increase Your Friends

1. Put a line in your email signature line that states “Dr. Smith is now on Facebook – Join facebook.com/drsmith”

2. Add a Facebook icon and link to your webpage

3. Announce your Facebook presence on a sign in your waiting room.

4. Make a Facebook announcement handout for patients to pick up in the waiting room and while checking out.

5. If you choose to Facebook, make sure to avoid doing it until you are blue in the face.

29 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

more important if your existing patients ask you a question in a public forum. Since you have already established a doctorpatient relationship, your answer may be seen as violating your patient’s privacy. Additionally, social media sites are not secure or HIPAA (Health Insurance Portability Affordability and Accountability Act) compliant. Social media sites also allow links to outside content such as your own website or an article of interest. Even videos such as your appearance on news stations or video content that you may have produced may be used. Patients especially appreciate video content since it allows them to see you and hear your explanations. Many people choose to repost these videos for others to see, and in this manner your content may be spread throughout the Web. You can learn to produce video content on your own computer with a connection to an inexpensive webcam. Most teenagers will be able to show you how to do this and to make it look semi-professional. Patients do not necessarily expect studio quality videos, nor is this feasible for most physicians. Remember to keep your content general and do not give personal medical advice.

Keeping “Friends” Friendly While social media encourages connections and lively discourse, sometimes this discourse becomes abrasive. The virtual anonymity of internet-based communication may encourage normally polite individuals to write things that they would never say face-to-face. This type of communication may be damaging to your professional reputation or create an environment not conducive to positive medical discourse. Most people on the internet will understand that angry and rude comments should be ignored. But in order to safeguard against this, you may want to make your social media presence unidirectional and to moderate all comments. While this may increase the amount of time that you need to invest in your social media campaign, it will also allow you to control your face to the world. These words of caution shouldn’t be used an excuse to avoid social media since even without ever posting anything online, physician rating websites where patients rate physicians have become popular. They are mostly unmoderated. Some of these sites are very simplistic with a thumb up or down, and while the comments posted by patients may seem preposterous to you, potential patients do visit these sites and make decisions about which doctor to see based on the ratings. Sometimes, however, these comments step over the line and may be seen as libel. The Florida Medical Association has endorsed Medical Justice, a company designed to help safeguard your reputation by reacting legally to these harmful or defaming comments. The potential for negative comments is actually one of the best reasons to have a strong social media presence. It is the best way for you to control your own web presence. This means that when potential patients search for you on the Web, they won’t only see comments made by others on 30 Vol. 62, No. 4 2011 Northeast Florida Medicine

rating websites, but this may be drowned out by positive, useful content created by you, the physician.

Conclusion While you should proceed with a social media campaign with some caution, there is no question that your patients and potential patients demand it of physicians. Whether you are ready or not, for Facebook, Twitter, a website or anything social media has to offer, the public is ready. They are online and looking for you. Start to research how you, your practice and your expert advice can get “out there” to a growing audience. Once you do, there will be no turning back, and that won’t even be a consideration because you will be hooked, or should we say “LinkedIn”.

Resources:

Major Social Media Websites: This is not a comprehensive list of social media outlets, but it may be used as a starting point in understanding the reasons to explore these sites further. • • • • •

Facebook – The most popular social media site with more than 300 million users. People link up with Friends. Go to http://www.facebook.com/help. Google+ – In 2011, Google entered the world of social media and has created its own site to compete with Facebook, but Google+ has not yet attracted nearly as many users. Go to https://plus.google.com. LinkedIn– As opposed to the other social media sites discussed in this article, LinkedIn is mostly a way for professionals to network and to post resumes/accomplishments. Go to http://linkedin.com. Myspace – A social media site that predated Facebook, but that is not currently as popular with adults. Go to http://myspace.com. Twitter– A site where you can post 140 characters (tweets) at a time. This limitation also makes it useful for busy physicians. Go to http://twitter.com.

Examples of Social Media Usage: http://blogspot.neurologique.com

http://facebook.com/Neurologique https://plus.google.com/105771490907410660075/ http://linkedin.com/in/Neurologique http://myspace.com/Neurologique http://world.secondlife.com/resident/aff4b366-0d61-43609a3a-d0931c649842 http://twitter.com/Neurologique http://ustream.tv/channel/Neurologique http://youtube.com/Neurologique

www . DCMS online . org

HIPAA and the Internet Christopher L. Nuland, JD

Introduction In an era in which patients are demanding more information and are unwilling to wait for normal appointments, health care providers are hard-pressed to the provide meaningful information while still complying with strict medical confidentiality laws. The essential tension between the Health Insurance Portability Affordability and Accountability Act of 1996 (“HIPAA”) and the current era of immediate online gratification is often frustrating to each side, but, as this article will demonstrate, it is not insurmountable. As with all interactions between providers and patients, managing the expectations of each party is essential to the success of any online program. In other words, patients need to understand immediately that, while a provider may be doing everything possible to provide requested information as quickly and completely as possible, outside factors such as HIPAA preclude the patient from having unfettered access to such information.

What HIPAA Requires The HIPAA Security Rule requires that “covered entities” (including all providers of health care) take “reasonable” precautions to protect the privacy and security of so-called “Protected Health Information” (“PHI”). It is essential to understand that PHI includes far more than just traditional medical records. In fact, any information that could even tie a patient to a specific provider of health care, as well as any personal information regarding that patient, would constitute PHI. Of course, HIPAA does allow the patient to request copies of their own medical information, and no provisions in HIPAA or Florida law preclude the online dissemination of such information in accordance with the patient’s wishes. The key is to ensure that it is the patient’s wishes that are being obeyed. It is the first priority of the provider to obtain a written consent of the patient. While such consents can be performed online if the patient can produce sufficient personally identifiable information to authenticate the patient’s identity, in-person authentication is preferable, as an examination of a driver’s license or other form of picture identification remains the best way of authenticating a patient’s identity. Simple consent, however, is not enough. Under HIPAA’s Security Rule, it is the provider’s responsibility to ensure Address Correspondence to: Christopher L. Nuland, JD, 1000 Riverside Avenue, Suite 115, Jacksonville, FL 32204. Email: nulandlaw@aol.com 31 Vol. 62, No. 4 2011 Northeast Florida Medicine

the security of the transmitted information by adhering to eighteen different standards for the transmission of such data, each of which must be documented. A description of each of these standards is found in the HIPAA Security Rule. They are divided into Administrative, Physical, and Technical categories as follows:

Administrative Safeguards

1. Security Management Process Standard: The practice is required to perform a risk analysis and information system review to ensure that there are no inherent, controllable risks in the system. Most HIPAA Compli ance Plans include such risk analysis tools, as do most health care attorneys in Northeast Florida. If and when such risks are identified, the practice must then take documented steps to address the identified threats. 2. Assigned Security Responsibility Standard: The pratice’s existing HIPAA Compliance Officer may serve in this position, which requires that an identifiable individual within the practice be ultimately responsible for compliance issues. With regard to Internet exchanges with patients, responsibility for such communications should be limited to specific individuals. 3. Workforce Security Standard: The practice must de termine who within the office should have access to PHI and under what circumstances, and must ensure that such access is terminated upon termination of employment. Likewise, upon termination of employ ment, all keys, hardware and software should be re turned, and any passwords associated with the separat ing staff member should be rescinded. Again, only those assigned the responsibility of communicating with patients should have access to the system. 4. Information Access Management Standard: The Prac tice must have policies and procedures as to how autho rized persons may access information, such as passwords for electronic information.This standard is equally important for staff members and for patients, each of whom should have separate means of accessing only the information necessary to comply with the specific data request. 5. Security Awareness and Training Standard: All staff must be trained in the new security standard and its applicability to Internet communications. This train ing may be combined with the HIPAA Privacy training, but experience has shown that documented attendance of all staff is critical. Of course, instruction on the nu ances of Internet communication should be included in any such training. 6. Security Incident Procedures Standard: Even under the best of programs, unauthorized disclosures are bound to occur. The Practice must therefore have policies and procedures to deal with unauthorized disclosures, in cluding the documentation of such disclosures and efforts to mitigate the harmful effects of any such breach. www . DCMS online . org

7. Contingency Plan Standard: Likewise, the office must have policies to deal with the sudden loss of PHI, in cluding data backup and an emergency plan. 8. Evaluation Standard: This standard requires the Practice to periodically evaluate itself to determine if it is in compliance with the Security Regulations. Again, compliance with this (or any other) standard does not necessarily require the engagement of outside personnel. However, the person(s) responsible for this task will document the results of such an audit, as well as the date of such audit, and shall present the results to the HIPAA Security Office. Any necessary correc tive action will be taken no later than 30 days after such a finding is made. 9. Business Associates Standard: As in the Privacy Rule, Business Associates who may have access to the system must guarantee that they will provide security for PHI, as well as identify and mitigate any inadvertent disclo sures.

Physical Safeguards

• Facility Access Controls Standard: The Practice must have policies and procedures to control access to PHI and the facility. Only authorized staff shall have access to PHI, and such access shall be restricted to a need to know basis. Should a staff member be found to have violated this policy, disciplinary action should be taken. • Workstation Use Standard: The Practice must have policies and procedures detailing what may or may not be done at a workstation, including protocols for secur ing workstations at the conclusion of each workday. • Workstation Security Standard: Policies and proce dures must be developed and implemented to ensure that only authorized employees have access to worksta tions. Patients and guests shall not be allowed in work station areas and workstation computers shall be located in such a way so that the screens may not be regularly visible by patients or guests. • Device and Media Controls Standard: Offices must have policies to ensure that hardware, software, and media storage are erased before being disposed, reused or leaving the building.

Technical Safeguards

• Access Control Standard: Access to electronic PHI, either by patients or staff, must be restricted by office policies that require unique user identification, emer gency access procedures, and disclosure to staff and patients as to when information may be accessed and the inherent limitations of such access. • Audit Controls Standard: The actual systems that house PHI must be audited/inspected periodically to ensure the integrity of electronic PHI. • Integrity Standard: Finally, Practice Policies and Procedures must be in place to ensure that electronic PHI cannot be inappropriately altered or destroyed. ] 32 Vol. 62, No. 4 2011 Northeast Florida Medicine

Managing the Risks While technical compliance with the above standards is essential to maintaining HIPAA compliance, perhaps a bigger challenge for the Practice is managing the expectations of the patient. Research and personal experience have shown that most HIPAA and malpractice claims are brought by patients who have unrealistic expectations as to what the health care provider could offer. No interactive Internet system can be instantly available at all times, and there are logistical barriers to providing the full range of information and medical records for which a patient may ask. Therefore, it is essential that patients be informed as to what the Internet access program can and cannot do, what the typical response time might be, and what to do if the patient believes that they are having a medical emergency. All too frequently malpractice cases stem from the errors and omissions of administrative staff in recording patient phone and Internet communications. Therefore, health care providers and their staff should be cognizant that the contents of any internet communication should be included in the patient’s medical record. Only in this way may the practice protect both itself and the patient from future misunderstandings as to what information has been disseminated. Finally, care should also be taken when participating in online forums and social media. Because patients are likely to rely on any advice that is given over the Internet, one could argue that a patient-physician relationship could be formed, along with all of this relationship’s inherent risks and dangers. Therefore, physicians should limit their online posts to statements of general medical education, avoiding any statement that could be construed as a diagnosis or treatment recommendation. Ideally, such posts would include a disclaimer that directs the patient to seek personal professional assistance from a qualified physician.

Conclusion While the above may appear daunting, many practices have found that creating an interactive patient portal saves staff and provider time and can lead to happier patients, who often can obtain vital information without having to wait for routine appointments. Also, the cost of such a system need not be prohibitive, as the increasing use of such systems has made everything from the legal consents to the actual software more readily available at an affordable price. Nevertheless, as this article has shown, such programs need to be established with care and with constant vigilance being necessary to protect the provider from regulatory and malpractice risks. The good news is that most health care attorneys are wellversed in the above requirements and can provide appropriate, inexpensive guidance.

www . DCMS online . org

Technology for the Physician Danielle S. Walsh, MD, FACS Abstract: Just as each medical journal brings a new round of knowledge to assimilate into our patient care paradigm, each day brings new technology into the digital world, gradually transforming the landscape of how we create, share, and utilize information. Physicians have been leading the adoption curve of these technologies, in both the personal and professional spectrum.1 While some may professionally equate integration of technology with adoption of electronic medical records, so much more is available. This article reviews a variety of resources available for improving your efficiency, online presence, and digital communication outside the spectrum of electronic medical records.

practice prides itself on ensuring each patient gets the time and attention he/she needs for the type of problem you treat, and that this, unfortunately, sometimes leads to unexpected delays. Avoid directly engaging in any criticism in a review to ensure there is no perception of breech in patient confidentiality. Additionally, encourage patients who are satisfied with your care to post positive reviews. The presence of multiple positive reviews can often lessen the impact of an occasional negative one.5

Website Marketing

Other tools in creating an online presence include a practice website, instructional media, and web based consultation. While web design used to require a programmer, a number of programs are available for free or a small fee that guide you through a simplified process. Among the highest rated include Intuit Website Creator, Web Easy Professional, and Yola Silver.6 Instructional media encompasses an assortment of tools to assist patients in learning about the type of problems you treat. The information can be added to your website, distributed as digital newsletters to news sites, posted with disease specific online patient communities, or even linked to a hospital homepage. Examples include patient information sheets for viewing and download, access to before and after treatment photographs, or instructional videos of the physician actually lecturing on a subject. Youtube.com Some physicians elect is a web based library of videos into which users to demonstrate their can upload and view technical skills or create digital media on almost marketing videos...to any topic for free. Some physicians elect to dem- attract patients. onstrate their technical skills or create marketing videos for this site to attract patients. Though still a fledgling field, web based consultation has begun to gain steam. A number of companies aim to satisfy the consumerâ&#x20AC;&#x2122;s desire for immediate physician feedback from the comfort of their own home.7 These consultations may range from a text exchange to a scheduled video link in which the patient and physician interact live via web cameras. By joining with one of these firms, opportunities for offering your professional services move well beyond the local area.

Physician advertising has been frowned upon, and even legislated, but physician marketing is not only accepted, but an industry unto itself.2 A brief web search will reveal a significant number of companies willing to establish a plan of website, twitter, and video presence to attract patients, promote your practice, and demonstrate your skills in the digital world â&#x20AC;&#x201C; for a fee. Additional services may include development of brochures, organization and scheduling of seminars, performance of demographic analysis, and creation of complete practice strategic planning. Use is not just limited to private practice groups looking to attract new patients. Medical students and residents use institution websites in deciding where to pursue training and for employment considerations.3 Even if physicians choose not to create an online presence for their practices or themselves, one has likely already been created for them. At least seven different organizations provide online information and reviews of your practice, all without need for you to request inclusion. Basic information, such as practice type, location and phone number are commonly free, but a more thorough report with patient reviews, training and background, and malpractice record are available for fees in the range of $10 per report.4 (DCMS has an online Physician Directory. Go to dcmsonline.org/directory) With few exceptions, most physicians can take charge of their own marketing with some easy steps. First, perform a web search of yourself. Enter your own name, credentials, and city and see what comes up. Check the accuracy of the information and contact the webmaster of the site if any information is misleading or untrue. If negative patient reviews are posted, these may be more difficult to have removed. However, some sites will allow you to post a response. When doing so, word your response in a positive light. For example, if a patient complains of a long wait, comment on how your Address Correspondence to: Danielle S. Walsh, MD, East Carolina University, 600 Moye Blvd, PCMH TA-207, Greenville, NC 27834. Email: walshd@ecu.edu.

33 Vol. 62, No. 4 2011 Northeast Florida Medicine

Email and Other Social Media The fledgling internet came alive in 1969 â&#x20AC;&#x201C; the same year man set foot on the moon.8 Its use exploded in the 1980s and 1990s and became entrenched in the medical arena by the end of the 20th century. Initially used by most physicians just for email, it now serves as the backbone for full-fledged

www . DCMS online . org

patient care. A study by Google in 2009 found 86% of US physicians use the internet to garner information on health, diseases, and medications and 59% did so from a mobile device.9 More controversial for physicians is whether email should be used for communicating with patients. In 2009, a survey found that 42 percent of physicians were communicating with patients online10 That same year, the HITECH Act to enforce HIPAA confidentiality protections for electronic health records came into practice, placing the onus on the physician to ensure their electronic communications are secure.11 As such, electronic communication must be encrypted, a service not available in most commercial email services. Patients should provide written consent for using email, and physicians should develop guidelines for how to handle communications. For example, patients may need to be advised on how long it will take for a physician response, what to do if the problem is emergent, and when the physician is unavailable. An automated response to a unique patient email account can help manage these potential issues. Additionally, the HITEC Act requires that “date, time, patient identification and user identification, must be recorded when electronic health information is created, modified, deleted or printed, and an indication of which actions occurred also must be recorded.”10,11 The onus is on the physician to maintain these records, a clear detraction for many. Other recommendations for use of email with patients include confirming an email address is correct, avoiding the forwarding of emails, and disabling junk filters to minimize the inadvertent discarding of a patient email.12 Texting or text messaging is the typing and immediate transmission of the message to another via cellular phone lines. While most cellphones have texting Younger physicians, capabilities, texting may not be included in the in particular, have base wireless phone plan. embraced texting as a Unlike email, the mesprimary form of comsage is usually concise, often uses abbreviations, munication.... and the sender typically expects a reply within a few seconds to minutes. Younger physicians in particular, have embraced texting as a primary form of communication, greatly preferring it to phone calls or emails. Some physicians have advocated it as quieter than a phone call in the already noisy hospital environment, and it could alleviate some privacy concerns when needing to communicate about a patient in a public setting.13 Since texts are not encrypted, there are concerns about possible HIPAA violations should the text be sent to the wrong wireless or be intercepted. A common sense approach to this technology may be to use texting for keeping up with patient conditions or circumstances, but not detailed medical recommendations. Quick responses, such as “schedule for surgery” or “meet in office at 3pm”, but avoiding the use of identifiers may minimize risk. It remains 34 Vol. 62, No. 4 2011 Northeast Florida Medicine

an excellent tool for office staff communications, personal communication and schedule updates.13 Online social networking refers to the interaction of individuals with a common interest into groups, usually through a particular website host. Some of the more commonly used sites include Facebook, MySpace, LinkedIn, and Bebo, and of these, Facebook is the most commonly used.14 The sites allow users to create a “page” describing a person, business, or even a concept, add photos, and maintain an ongoing conversation with others who become “friends” of that site. Twitter, a popular social networking platform, allows users to publish and receive short (140 characters or less) “tweets” as texts to their digital devices. Users do not have to log in to a website to catch up on the latest information, and they are not limited to informing just a handful of individuals about what is going on. Surgeons have used tweets throughout an operation to inform family members and others interested in how the procedure is going, what steps are being performed, and what to expect next.15 Other uses include keeping updated on events in a medical conference, campaigns for awareness of health issues, and even appointment reminders.16,17 A recent study found that 87% of U.S. physicians use at least one form of social media for personal purposes. Professional use lags behind, but continues to rise, reaching an impressive 67%.18 Social media’s rapid adoption in the physician arena led the American Medical Association to publish a policy on professional use of social media in August 2011.19 In it, they encourage physicians to separate their personal and professional accounts, ensure privacy settings are used, and frequently vet the content posted to their sites.

Mobile Devices While most physicians find desktop computers in the office and at the nurse’s station, portable computing now leads the way in digital access. As opposed to the wired connections found in most hospitals, the medical world is increasingly transitioning into the wireless mode of data exchange. While the hardware of how that signal is created is largely determined by the IT department of a hospital or practice, the device used to access that signal varies tremendously from physician to physician. Among the most popular devices for mobile computing are smartphones, tablets, and ultraportable laptops. The Personal Digital Assistant (PDA) of the 1990s merged with the cellular phone to create a single “smartphone” used by 35% of all Americans and an astounding 72% of US physicians.20,21 A smartphone can send and receive not only phone calls, but emails and text messages. It maintains your schedule and synchs with your main computer for seamless schedule changes. Smartphones allow for a wide array of software or applications (also called ”apps”), to include entry of CPT and ICD-9 codes into a database, calculation of medication doses, review of radiographic images and patient charts, and so much more. Design varies from a full, albeit miniaturized, keyboard and screen to a non-keyboard touch screen design. The four most popular platforms, in order of www . DCMS online . org

market share, include the Google Android (41.8%), the Apple iPhone (36.4%), the Research in Motion (RIM), BlackBerry (21.7%), and the Microsoft Windows Phone (5.7%).22 Each has their pros and cons. To help guide the user to the most ideal selection, it is good to discuss with co-workers who use different smartphones, talk to your hospital or practice Information Technology (IT) department, and have a handson trial of each device in a store carrying a variety of them. Tablet computers first entered the digital world in 2000, but the trickle of use became a geyser in April 2010 with the introduction of the Apple iPad.23, An estimated 30% of physicians now use an iPad or similar tablet, a rate almost five times greater than the general population.24,25 While they do not function as cellphones, the large, crisp screen permits physicians to review imaging studies, show patients images or even videos relevant to their diagnosis, and perform research and email with ease on the go. Users who struggle with the small keyboards on smartphones are often attracted to the larger format and ability to connect to more traditional keyboards. Some physicians find the touch format easier to learn as it is more intuitive than the typed search function of other devices.25 Ultra-laptops, netbooks, and traditional laptops bring additional bulk and size, but with the added benefit of power and memory. Many physicians prefer these devices for their ability to capture patient encounters with electronic medical records (EMRs) in a way not possible on the smaller smartphone or tablet. Due to the additional hardware and screen size, battery life may be limited to less than 3 hours without a charge or a battery pack. However, physicians using EMR in a variety of locations on the same day may prefer the ergonomics and clear graphics of the laptop while maintaining portability. Each class of devices carry pros and cons as do the individual devices of each class. Frost & Sullivan, a consulting firm, recently studied the process of selecting a wireless device, and developed seven criteria for consideration: functionality, usability, security, network connectivity, durability, application availability and price.26 Functionality and ease of use are very individualized and may be best evaluated by the user. Battery life, screen size, type of keyboard or input device, durability, and compatibility with other electronics also are considerations. The ability to connect to your workplace network, the availability of local service providers, and the strength of the signal reaching your device in the common areas you wish to use it should all be considered. Devices do break, and investment in a protective cover and insurance against breakage not covered by a warranty should be considered. Security is essential for any physician who intends to use the device for identifying patient or personal information. Minimal security should consist of a password protection to enter the device each and every time. Additional security may include encryption, limitation of email available on the device to 14 days or less, and ability to remotely remove all information on the device should it be stolen. 35 Vol. 62, No. 4 2011 Northeast Florida Medicine

Other Technologies The adoption of electronic medical records has created the need for physicians to input significantly more data into a computer system. Manual entry by typing is time consuming and dictation via a transcripThe adoption of electronic tion service is costly.27 Speech medical records has created the r e c o g n i t i o n need for physicians to input software, such significantly more data into a as market share computer system. leader Dragon Dictation, allows a physician to dictate emails, patient notes, and more into a microphone with near instantaneous transcription. Though earlier versions of the software were deemed frustrating to many, newer versions with improved microphones have 95% accuracy, allow speech rates up to 160 words per minute, and in many cases, allows you to command the software you are dictating into.28 Some physicians still eschew the need to edit their own dictation and user adoption is likely to be very individualized. Cloud computing refers to technology that runs on the Internet and uses shared resources that can be accessed, expanded, and updated quickly. For the physician, the embrace of cloud computing can result in both efficiency and cost savings.29 Most physician practices currently purchase a server for their office on which they store all their patient records, data and software to permit users in the office to all access the information from different computers. In this format, an information technology specialist is paid to perform updates and maintenance of the server. With cloud technology, the server is in an alternate location, maintained by the company that owns it, with multiple users, and can be reached with any computer or mobile device with internet access. The resulting lower cost and improved access make this up and coming technology appealing to small practices, in particular. As with all electronic systems, HIPAA compliance must still be ensured.30

Summary Healthcare technology has already changed the way physicians live, both professionally and personally. Physician marketing has moved to the mainstream via the internet and social networking. Smartphones and wireless devices have improved communication and efficiency. Technology continues to evolve quickly, and the use of remote access to patient records, scientific data, and even real-time patient data promises to continue altering the way we practice medicine. Digital technology aims to improve the lives of both patients and physicians, not unlike the medical research we depend on for advancement. www . DCMS online . org

Selected Websites, Software, and Applications Physician Information

• American Medical Association-http://www.ama-assn. org/ • American Medical Association CPT coding app- http:// www.ama-assn.org/ama/pub/about-ama/apps.page • Epocrates-medication and prescribing guide http://www.epocrates.com/ • Florida Medical Association- http://www.flmedical.org/ • DocGuide- recent publications. http://www.docguide. com • Duval County Medical Association-http://www.dcmsonline.org/ • HealthStream-CME and simulation.http://www.health stream.com/index.aspx • Medscape (formerly eMedicine) clinical reviews- http://www.medscape.com/ • Sermo- social medical discussion. http://www.sermo. com/ • UpToDate (subscription) comprehensive clinical updates. http://www.uptodate.com/index • Zygote Body (formerly Google body)- anatomy. http://www.zygote.com/

YGSaEP2uLrswmLmo1fTuf15rQ_20061130.html?mod=tff_ main_tff_top . Accessed on 10/15/2011. 5.

Lefebvre C. How doctors can manage negative content online. Available at: http://www.reputation.com/how_to/ how-doctors-can-manage-negative-content-online/ Accessed on 10/15/2011.

Top Ten Reviews. 2011 Compare Best Website Creation Software. Available at: http://website-creation-software-review. toptenreviews.com/ Accessed on 10/15/2011.

Web Rich Marketing. Obtain remedy via online medical consultation. Available at: http://www.articlesbase.com/ wellness-articles/obtain-remedy-via-online-medicalconsultation-4487062.html. Accessed on 10/15/2011.

Rosenbaum P. Web pioneer recalls ”birth” of the Internet. Available at: http://articles.cnn.com/2009-10-29/tech/ kleinrock.internet_1_internet-leonard-kleinrock-computer?_ s=PM:TECH. Accessed on 10/05/2011

Dolan PL. 86% of physicians use Internet to access health information. American Medical News. Jan 11, 2010;l54(1), Available at: http://www.ama-assn.org/amednews/2010/01/04/ bisc0104.htm. Accessed on 10/05/2011.

Patient and Physician Information

• American Academy of Family Physicians- http://fami lydoctor.org/online/famdocen/home.html • American Academy of Pediatrics-http://www.aap.org/ • American Medical Association-http://www.ama-assn. org/ama/pub/patients/patients.page? • Centers for Disease Control and Prevention-http:// www.cdc.gov/ • Centers for Medicare and Medicaid-http://www. medicare.gov/ • Department of Health and Human Services-http:// www.hhs.gov/ • Health.com-http://www.health.com/health/ • National Institutes of Health-http://health.nih.gov/ • Medhelp-http://www.medhelp.org/ • Medline Plus-http://www.nlm.nih.gov/medlineplus/ • WebMD- http://www.webmd.com/

References

Weiss T. Doctors are heavy tech users – early adopters for healthcare technology. Available at: http://www.trendsspotting. com/blog/?p=2090 Accessed on 10/12/2011.

10. Segal J. HITECH act decrypted. Understand the law before you send your patients an email. Florida Medical Magazine. Winter 2011;54-60. 11. HITECH Act Breach Notification Guidance and Request for Public Comment Available at: http://www.hhs.gov/ocr/ privacy/hipaa/understanding/coveredentities/guidance_ breachnotice.html. Accessed on 10/10/2011. 12. Brown, J. E-mail is quick and easy, but it could become evidence in a malpractice suit. AAP News. October 2010;31:1,21. 13. Dolan PL. R U N2 TMing? American Medical News. February 4, 2008;13-14. 14. Wikipedia. Social Network Service. Available at: http:// en.wikipedia.org/wiki/Social_network_service. Accessed on 10/112, 2011. 15. Cohen E. Surgeons send ‘tweets’ from operating room. Available at: http://articles.cnn.com/2009-02-17/tech/twitter. surgery_1_twitter-and-facebook-social-networking-sitetwitter-tweeted?_s=PM:TECH. Accessed on 10/15/2011. 16. Pozo Jatem MC, Casey K, Kushner A. Can Twitter campaigns increase awareness about health issues? Bulletin of the American College of Surgeons. February 2011;96:44-45. 17. Peregrin T. Time to tweet: social networking for surgeons. Bulletin of the American College of Surgeons.February 2011;96:46-48. 18. Modah lM. Tompsett L. Moorhead T. Doctors, Patients & Social Media. Available at: http://www.quantiamd.com/q-qcp/ doctorspatientsocialmedia.pdf. Accessed on 10/15/2011. 19. American Medical Association. Professionalism in the use of social media. Available at: http://www.ama-assn.org/ama/ pub/meeting/professionalism-social-media.shtml. Accessed on 10/15/2011.

Texas Medical Association. The Regulation of Physician Advertising. Available at: http://rightnow.texmed.org/ci/ fattach/get/24756/ Accessed on 10/14/2011.

Kutikov A, Morgan TM, Resnick MJ. The impact of residency match information disseminated by a third-party website. J Surg Educ. 2009 Jul-Aug;66(4):212-5.

20. Pew Internet. Gadget Ownership Over Time. Available at: http://www.pewinternet.org/Trend-Data/Device-Ownership. aspx. Accessed on 10/05/2011.

Vara V. Sites offering data, reviews of doctors. Available at: http:// online.wsj.com/public/article/SB113259854512303267-WH

21. Dolan B. 72 percent of US physicians use smartphones. Available at: http://mobihealthnews.com/7505/72-percentof-us-physicians-use-smartphones/. Accessed on 10/05/2011.

36 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

22. Parr B. Android & iPhone dominate Smartphone Market at BlackBerry’s Expense. Available at: http://mashable. com/2011/08/30/android-iphone-blackberry-smartphonestats. Accessed on 10/05/2011. 23. Wikipedia. Tablet computer. Available at: http://en.wikipedia. org/wiki/Tablet_computer. Accessed on 10/09/2011. 24. Fuquay J. Doctors using smarthones, tablets to access medical data. Available at: http://www.star-telegram. com/2011/07/05/3201630/doctors-using-smartphonestablets.html. Accessed on 10/09/2011 25. Dolan PL. Doctors cite ease of use in rapid adoption of tablet computers. American Medical News. April 25, 2011;29. 26. Dolan PL. 7 things to consider when choosing mobile devices. American Medical News. September 12, 2011;40-42. 27. Torrieri M. Talk vs type: taking another look at voice recognition. Available at: http://www.physicianspractice.com/voicerecognition-dictation/content/article/1462168/1889679. Accessed on 10/15/2011. 28. Kleaveland B. Voice recognition technology. Available at: http:// www.physicianspractice.com/voice-recognition-dictation/ content/article/1462168/1589730. Accessed on 10/15/2011. 29. Dolan PL. Cloud computing: Is it right for your office. Available at: http://www.ama-assn.org/amednews/2010/10/18/ bisa1018.htm. Accessed on 10/15/2011. 30. HealthWorks Collective. Cloud computing in healthcare. Available at: http://healthworkscollective.com/nripAccessed on BW ad:adnihalani/24786/cloud-computing-healthcare. 4/19/11 4:16 PM Page 1 10/15/2011.

Serving Northeast Florida Since 1898

We proudly announce that First Professionals Insurance Company and The Doctors Company have united. Together, we set a higher standard. We aggressively defend your name. We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are the nation’s largest insurer of physician and surgeon medical liability. The Doctors Company and First Professionals

BUSINESS PERSONAL LIFE HEALTH

Insurance Company (FPIC) have officially joined forces. With the addition of FPIC, we have grown in numbers, talent, and perspective— strengthening our ability to relentlessly defend, protect, and reward our 71,000 members nationwide. To learn more about how we can protect your livelihood and reputation with our medical professional liability program, call

™

(800) 352-0320 or visit us at www.thedoctors.com.

We relentlessly defend, protect, and reward the practice of good medicine.

www.Vandroff-Insurance.com 5150 Belfort Road, Building 200 • Jacksonville, Florida 32256 904.296.3390 office • 904.296.6144 fax Copyright © 2011, Vandroff Insurance Inc. All Right Reserved. An Independent Insurance Agent®

37 Vol. 62, No. 4 2011 Northeast Florida Medicine

3454_FL_DuvalCMSnewsletter_Nov2011.indd 1

www . DCMS online .10/26/11 org

10:35 AM

Special - Changes to Preventive Care

An Overview of the Preventive Care Provisions of Health Care Reform Seth M. Phelps, Esquire

Background The Patient Protection and Affordable Care Act (ACA) signed into law on March 23, 2010 contained many immediate changes that affected group and individual health insurance coverage and coverage offered through self-funded group health plans. Coverage of preventive care, which officially became effective for plan years beginning on or after September 23, 2010, received significant attention from the media. However, what does the term “preventive care” really mean under the ACA and how does the mandate affect physicians in Northeast Florida?

Definition of Preventive Care As a general rule, the ACA requires that self-funded group health plans and insurers offer group or individual health insurance to: • provide coverage for certain preventive health care services, and not impose cost-sharing requirements (e.g. copayments, coinsurance, etc...) with respect to such services. Preventive care is not directly defined in the ACA. Instead, the ACA defines preventive care by reference to the following external sources: • Evidence-based items or services rated “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) • Immunizations recommended by the Advisory Com mittee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP) • Preventive care and screenings for infants, children, and adolescents, provided for in the comprehensive guide lines supported by the Health Resources and Services Administration (HRSA) • Additional preventive care and screenings for women as provided for in the comprehensive guidelines sup ported by the HRSA • Recommendations of the USPSTF regarding breast cancer screening, mammography, & prevention, ex cluding the recommendations issued in or around November 2009.

Address Correspondence to: Seth M. Phelps, Esquire, Assistant General Counsel with Blue Cross and Blue Shield of Florida Inc. in Jacksonville, FL. Email:seth.phelps@bcbsfl.com. 38 Vol. 62, No. 4 2011 Northeast Florida Medicine

Any services, tests, consultations or supplies identified in one of the above five sources is considered “preventive care” and generally must be covered subject to the exceptions/ limitations discussed. The federal government provides a comprehensive website that provides a complete list of the preventive care services and guidelines that physicians may find helpful. The website is: http://www.healthcare.gov/center/regulations/prevention/ recommendations.html.

Recent Notable Developments Several significant changes have already occurred that will impact, or have already revised the definition of preventive care for purposes of the ACA and health plan benefits. The website given earlier also notes specific changes. Those changes include:

USPSTF Changes

• The addition of screening and counseling for obesity in children beginning for plan years on or after January 31, 2011.

ACIP Recommendations

• Revisions to the HPV vaccination recommendations. HPV vaccination recommendations were expanded to cover the bivalent HPV vaccine. These revisions are effective for policy plan years beginning on or after January 8, 2011. • Revisions to the Flu vaccine recommendations. Expanded recommendations for adults, aged 19 to 49, were adopt ed. These changes become effective for plan years on or after March 2, 2011. • Revisions to the pneumococcal vaccine recommendations. Recommendations were adopted and become effective for plan years beginning on or after March 12, 2011. Changes include expanded use of the pneumococcal vaccine in children from 6 to 71 months. • Revisions to the combination measles, mumps, rubella, and varicella vaccine recommendations. The revisions become effective for plan years beginning on or after May 7, 2011.

HRSA Changes

• Revisions to the Heritable Disorders in Newborns and Children Comprehensive Guidelines. These revisions become effective for plan years beginning on or after May 7, 2011. Continued to p. 40 www . DCMS online . org

2011 Awards Presented at Annual DCMS-Navy Meeting The 2011 John A Beals Awards for Medical Research, the G. Shahin Awards for Research by a Physician in Training in Duval County and the Admiral Paul Kaufman Award were presented September 22, 2011 at the Annual DCMS-Navy Meeting. Beals Award winners are 1st Place - Dr. Zbigniew Wszolek and co-authors; 2nd Place - Dr. Mobeen Rathore and co-authors; and 3rd Place - Dr. Sandeep Grover and co-authors. Shahin Award winners are 1st Place - Dr. Eric Roberts and co-authors; and 2nd Place - Dr. Christopher Worley and coauthors. The Kaufman Award went to Dr. Tom Davis. (First photo, below L to R) Cmdr. David Boyd accepting for Dr. Worley, Dr. Zbigniew Wszolek, Dr. Joseph Tepas - DCMS Award Chair who accepted for Dr. Grover, Dr. Mobeen Rathore, and Dr. Eric Roberts. (Second photo, below L to R) Naval Air Station (NAS) Chief of the Medical Staff Cmdr. Jamie Oberman presents award to Dr. Tom Davis.

2011 DCMS Annual Meeting December 1, 2011 * 5:45-9:00 p.m. Hyatt Regency Jacksonville Riverfront

Ashley Booth Norse, MD, 125th President of the Duval County Medical Society

See Spring 2012 NEFM journal for Annual Meeting coverage

AMA Leadership Visit in April

The Beals Award was begun by Dr. John Beals to recognize outstanding research and publications by DCMS members. Dr. Shahla Masood created the Shahin Award in honor of her mother, G. Shahin, whom she considered an exemplary teacher. The Kaufman award is named after Admiral Paul Kauman, who was an NAS Commanding Officer and the award's first recipient, and honors a local physician or health care professional who delivers outstanding community service to NAS Jacksonville beneficiaries and staff. The NAS Hospital also presents its Circle of Excellence Award to recognize outstanding service to the NAS Jacksonville staff. This year's recipient was Nancy Silki. (not pictured)

39 Vol. 62, No. 4 2011 Northeast Florida Medicine

Jeremy A. Lazarus MD, the current President-Elect of the American Medical Association (AMA), will visit Jacksonville April 15-17, 2012. Dr. Lazarus will become the 167th AMA President in June, 2012. He is only the second psychiatrist in the AMAâ&#x20AC;&#x2122;s history to be elected to the position and the first since 1939. While in the area, Dr. Lazarus will speak at a DCMS dinner meeting, be keynoter at the Jacksonville Rotary Club, visit local academic medical institutions (UF College of Medicine and Mayo Clinic), The Florida Times-Union Editorial Board, and other area groups. The DCMS has been hosting AMA leadership for more than 20 years as a way to broaden the communityâ&#x20AC;&#x2122;s knowledge of organized medicine and to help motivate grassroots advocacy on issues of national importance. A clinical professor of psychiatry at the University of Colorado Denver School of Medicine and a voluntary professor of psychiatry at the University of Miami Leonard M. Miller School of Medicine, Dr. Lazarus is a distinguished fellow of the American Psychiatric Association and is widely published on issues of ethics, economics and managed care. His most recent book is entitled Entering Private Practice: A Handbook for Psychiatrists. www . DCMS online . org

Continued from p. 38

•

Women’s Health Guidelines. The new guidelines include expanded coverage for contraception (including over the counter drugs and devices) and sterilization services, breastfeeding support and supplies, domestic violence screening, and well- woman visits. These new guidelines become effective for plan years beginning on or after August 2, 2012.

of the exceptions applies, then, depending upon the plan, the provider type and the service, preventive care may not be covered without cost sharing. These exceptions demonstrate why it is important for physicians to verify health benefits to ensure that both the provider and the patient understand any applicable costs that may apply. The major exceptions to note are: •

Grandfathered Health Plans. A significant exception from application of the preventive care provisions of the ACA is for grandfathered health plans. Any health plan that was in existence prior to March 23, 2010 that continues with only relatively minor changes may be a grandfathered health plan and would not be required to comply with the preventive care provisions. Not all carriers have adopted this exception with respect to preventive care. Checking with the carrier is the best way to determine if the plan covers preventive care or is exempt because the plan qualifies as a grandfathered health plan. For more information on grandfathering, the following website is helpful: http://www.healthreform.gov/about/grandfathering.html

•

Out-of-Network Providers. While ACA did not specify whether the preventive care benefit applies to both contracting and non-contracting health care providers with a particular health plan, regulations issued by the United States Department of Health and Human Services (HHS) have confirmed that health plans are not required to provide the preventive care benefits at no cost sharing for out-of-network providers.

•

Value Based Insurance Designs. Some employers and health insurers are experimenting with what are known as value-based insurance designs (VBIDs) under the ACA. A VBID is a health plan that establishes different cost sharing, as an incentive for cost-effective use of medical services, based upon factors such as where the services may be delivered. Such VBIDs may have many such location based cost sharing differences or just a few. For example, a VBID may establish cost sharing for preventive care services at certain in-network locations (e.g. the primary care provider’s office) at 100% but require a copayment or other cost sharing at other in-network locations. Such an arrangement is allowed under current ACA rules with respect to preventive care but only so long as: 1.) there is an alternative for preventive care without cost sharing and 2.) the cost sharing at another location is waived if it would be medically inappropriate to have the preventive services provided in the favored setting based on the patient’s medical situation. In some respects, VBIDs have been in the marketplace for years with differences between inpatient cost sharing and outpatient. Now VBIDs not only include such location based distinctions but also, among other designs, potentially provider based and overutilization based distinctions.

Common Issues At first glance, it may appear that the application of preventive care benefits to health insurance coverage is fairly straightforward. Physicians, however, will find there are several areas where issues may arise concerning application of this ACA requirement. For example: • How many treatments/visits are covered? The guidelines, while providing appropriate general guidance for phy sicians, do not necessarily address the number of vis its or treatments that are covered over a specific period of time, e.g. annually, semi-annually, etc.., for a particular preventive care service. In such instances, checking with the patient’s insurance plan regarding coverage as well as reviewing the specific guidelines noted earlier from USPSTF, ACIP, and the HRSA are equally important. Continued clarification and guidance is ex - pected on the preventive care requirements under the ACA. • What physicians can deliver the treatment? In many instances the treatments, counseling, and other services recommended as preventive care could be delivered by a variety of medical provider types from counselors to physicians. This makes it important to understand not only if there are limits to the number of treatments covered but also whether the patient’s insurance coverage applies any limits on the types of medical providers that can deliver such preventive care services without cost sharing. • The recommendations have changed, so when do the changes become effective? As expected, revisions have already modified the definition of “preventive care”. Those revisions do not become effective until the first anniversary of the health coverage in question follow ing one year from the date of adoption. For example, the women’s health guidelines, adopted on August 1, 2011 will not start to become effective for plans until plan renewal following August 1, 2012. This may lead to confusion for physicians and patients over the effec tive dates of certain preventive care changes.

Exceptions/Limitations Several specific exceptions/exemptions to the preventive care requirements exist that affect whether a service is considered preventive care subject to the provisions of the ACA. If one 40 Vol. 62, No. 4 2011 Northeast Florida Medicine

Continued to p. 44 www . DCMS online . org

DCMS Membership Applications Richard D. Ten Hulzen, MD These physicians’ applications for membership in the Duval County Medical Society are now being processed. Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse, MD, DCMS Membership Committee Chair (904-244-4106 or Barbara Braddock, Membership Director (904-355-6561 x107).

Siddharth Bhatt, MD

Nephrology Clinic For Kidney Disease PA Medical Degree: Medical College of Baroda Residency: Stony Brook University Medical Center Fellowship: Boston University Medical Center Nominated by: Dinesh Jayadevappa, MD; Nilay Nahar, MD; Helder DePaiva, MD

Nitin S. Butala, MD

Neurology/Clinical Neurophysiology Baptist Medical Center/Baptist NeurologyLakewood Division Medical Degree: Grant Medical College Residency/Fellowship: Medical College of Wisconsin Nominated by: Mobeen Rathore, MD; Carlos Gama, MD; Rebecca Cooper, MD

Jennifer Chally, MD

Pediatrics Jacksonville Pediatrics Medical Degree: University of Miami School of Medicine Residency: University of Florida College of Medicine Jacksonville Nominated by: Randolph Thornton, MD; Thomas Stanley, MD; Nan McClelland, MD

Jasreman Dhillon, MD

Pathology UF Pathology Medical Degree: Postgraduate Institute of Medicine Residency: Winthrop University Hospital Fellowship: MD Anderson Cancer Center Nominated by: UFJP

Marc Kaye, MD

Orthopaedic Surgery The Bone & Joint Institute at Shands Medical Degree: Albert Einstein College of Medicine Residency: Cleveland Clinic Foundation, UCLA School of Medicine and Maimonides Medical Center Fellowship: University of Pittsburgh School of Medicine Nominated by: UFJP

Suparna R. Krishnaiengar, MD

Neurology The Neuroscience Institute at Shands Medical Degree: University of Mysore Residency: University of Oklahoma 41 Vol. 62, No. 4 2011 Northeast Florida Medicine

Fellowship: Oklahoma University Health Sciences Center and Cleveland Clinic Foundation Nominated by: UFJP

Robert M. Levy, MD

Neurosurgery UF Neurosurgery Medical Degree: Stanford University School of Medicine Internship: Stanford University School of Medicine Residency: University of California Nominated by: UFJP

Jeannine V. Mauney, MD

OB/GYN St. Luke’s OB/GYN Medical Degree: Wake Forest University School of Medicine Residency: University of Florida College of Medicine-Jacksonville Nominated by: Guy Benrubi, MD; Andrew Kaunitz, MD

Carolyn B. Messere, MD

Colon & Rectal Surgery Colon & Rectal Associates Medical Degree: University of Massachusetts Medical School Residency: Baystate Medical Center Fellowship: Carle Foundation Hospital Nominated by: Frank Healey, MD; Robert Moore, MD; Frank Chrzanowski, MD

Michelle Stalnaker, MD

Obstetrics & Gynecology Care Center for Women at Shands Medical Degree: University of North Carolina School of Medicine Residency: University of Florida Health Science Center/Jacksonville Nominated by UFJP

Alexander Tuan Rose, MD

Trauma/Critical Care Surgery UF Trauma Surgery Medical Degree: Wayne State University Medical School Internship/Residency: Wayne State University Fellowship: University of Florida Health Science Center/Jacksonville Nominated by: UFJP

Jason P. Scimeme, MD

Pediatric Critical Care UF Pediatric Critical Care Medicine Medical Degree: SUNY Upstate Medical University Residency: Long Island Jewish Medical Center Fellowship: Nationwide Children’s Hospital Nominated by: UFJP

Ophthalmology/Glaucoma Specialist Beaches Eye Center Medical Degree: Mayo Medical School Residency: Mayo Clinic Fellowship: Wills Eye Hospital Nominated by: David Pearson, MD; Donald Barnhorst, MD; Kent New, MD

Christine Thorogood, MD

Pediatrics UF Pediatric Service Medical Degree: Robert Wood Johnson Medical School Residency: Thomas Jefferson University/ Alfred DuPont Hospital for Children Nominated by: UFJP

Gladys P. Velarde, MD

Cardiology The Cardiovascular Center/UF Medical Degree: New York University School of Medicine Residency: Columbia Presbyterian Medical Center Fellowship: Boston University and Mount Sinai Medical Center Nominated by: UFJP

Thomas Wannenburg, MD

Cardiology The Cardiovascular Center/UF Medical Degree: University of Natal Medical School Residency: John Hopkins Bayview Medical Fellowship: Wake Forest University/Baptist Medical Center Nominated by: UFJP

Raquel S. Watkins, MD

Allergy & Immunology Watkins Allergy & Asthma Clinic Medical Degree: University of Maryland School of Medicine Residency/Fellowship: Wake Forest University/Baptist Medical Center Nominated by: Bradford Joseph, MD; Vikram Gopal, MD; Sanjay Swami, MD

Velyn Lisa Wu, MD

Family Medicine Family Care Partners Medical Degree: University of South Florida College of Medicine Residency/Fellowship: Halifax Health Nominated by: William Carriere, MD; TraChella Johnson, MD

RESIDENTS/FELLOWS – MAYO CLINIC Anesthesiology John Douglas McDonald, MD Ajay Rajkumar Vellore, MD

www . DCMS online . org

DCMS Membership Applications Behavioral Neurology Qurat Ulain Khan, MD Cardiology Preetham Kumar, MD Dermatology Brent Goedjen, MD Hematology-Oncology Faithlore P. Gardner, MD Jason Starr, DO Internal Medicine Asim Ahmad, MD David Cangemi, MD Jennifer Horsley-Silva, MD Juan Carlos Leoni-Moreno, MD Cletus Tanwi Moma, MD Julia Mueller, MD Ricardo J. Pagan-Lopez, MD Cara Prier, MD Carl Ruthman, MD David F. Snipelisky, MD Oral Waldo, MD Neurology Kirstin Eller, MD Rebecca Hurst, MD Glen Robinson, MD Amita Singh, MD Julia Whitlock, MD Pulmonary/Critical Care Medicine Lioudmila Karnatovskaia, MD Philip E. Lowman, MD Jose M. Soto Soto, MD Radiation Oncology Corey Hobbs, MD Radiology William Justin Reed, MD Joseph Whitlock, MD Transitional Year Jordan Michael Brown, MD Jason Sebesto, DO Blake Michael Troiani, MD

RESIDENTS/FELLOWS – UNIVERSITY OF FLORIDA Cardiovascular Disease Alian Aguila, MD J. Ryan Altman, MD Line Kemeyou, MD Raguveer Murthy, MD

Joshua Holliday, MD Brett Horgan, DO David Martineau, DO Emergency Medicine Karissa Cerroni, MD Paul Diaz-Granados, MD Susan Goggans, MD Angel Harper, MD John McLain, MD Amber Newell, DO Nataly Saldana, MD James Wheeler, MD Jennifer Wilkerson, DO Endocrinology Hagop Kojanian, MD Anna Szafran-Swietlik, MD Gastroenterology Bijo Kythaparampil John, MD Camille McGaw, MD Infectious Disease Diane Vanhorne-Padilla, MD Internal Medicine Ahmad Alkaddour, MD Christopher Bailey, DO Jason Bellardini, MD Jason Hew, MD Alexandra Joseph, MD Christina Kanacheril, MD Aisha Khan, DO Paul Maraj, MD Trevanne Matthews-Hew, MD Garry McCulloch, MD Ke Ning, MD Michael Pizzi, DO Avinash Ramdass, MD Wesley Thompson, DO Jean Touchan, DO Kasey Treger, DO Interventional Cardiology Shahdad Azmoon, MD Nephrology Qurrat Shamim, MD Neurology William Bossert, MD Lina Rodriguez Rosario, MD Khadijah Shamseddine, MD Denys Shapovalov, MD

Clinical Cardiac Electrophysiology Bosede Afolabi, MD

Obstetrics & Gynecology Oluwakemi Adegoke, MD Dawn Bowers, MD Rachel Cartechine, MD Amy Hammers, MD Robert Knowlton, MD Kristen McMaster, MD

Diagnostic Radiology Mona Ahmed, MD Sara Fernandez, MD

Orthopedic Surgery Anna Acosta, MD Mark Elliott, MD

42 Vol. 62, No. 4 2011 Northeast Florida Medicine

Kyle Fleck, MD William Toole, MD Pathology/Anatomic & Clinical Dawn Butler, MD Deepan Mathur, MD Kerry Nagee, MD Pathology/Cytopathology Marisa Varallo, MD Pediatrics Concepcion Agnila, MD Sarah Bajorek, DO Joshua Berg, DO Ryan Cantville, DO Craig Erker, MD Adriana Martinez, DO Alexander Ortega, MD Emmanuel Pena, DO Kaitlin Porcaro, MD Adam Rappoport, MD James Sierakowski, DO Youness Tolaymat, MD Pediatric Endocrinology Ranjana Sarma, MD Pulmonary/Critical Care Medicine Hammad Bhatti, MD Surgery Mahir Alsalman, MD Amanda Bailey, DO Lori Gurien, MD Timothy Hester, MD Chad Kaplan, MD Esther Mihindu, DO Martin Rosenthal, MD Yauhen Tarbunou, MD Surgical Critical Care Angela Jones, MD Jason Moore, MD Vascular & Interventional Radiology Ryan Daily, MD

Did you know about this?

Referral? Phone Number? Address or Directions? Use the DCMSonline Physician Directory on your Smartphone!

You can easily search for a DCMS member’s practice information and get a map and directions to their office. Check it out

www.db.dcmsonline.org/directory or use your SmartPhone QR reader!

Stay Connected!



www.dcmsonline.org

Go online and take a look!

www . DCMS online . org

Look how far we have come in 159 Years! The Duval County Medical Society (DCMS) has been keeping in touch with its members and communicating important medical news and events for 159 years. • In 1853 when it all began, information from DCMS meetings was recorded in handwritten minutes and then spread by word-of-mouth, posted notices in offices and hotel lobbies, or published items in the newspaper. •

Fast forward to 1933 when a legal size printed Monthly Bulletin of the Duval County Medical Society was folded down to business envelope size and mailed to the membership with a 11/2 cent stamp.

•

This progressed to a 30-page saddlestiched 5” x 8” booklet, then to the 40-page 7” x 9” Jacksonville Medicine, and eventually a full-size journal publication called Northeast Florida Medicine. Telephone calls, faxes and mailings supplemented any print communication tools.

•

Then the computer age hit, so phones, faxes and even electric typewriters were abandoned for the technological advances of PCs, email, websites, Smartphones, Facebook and Twitter.

•

Today DCMS members get Society information through an e-newletter, a dcmsonline.org web announcement, by reading the virtual edition of the journal, or hearing about it all via social media.

We have come a long way! The fascinating story of DCMS will be available soon in a book tentatively entitled Florida’s Pioneer Medical Society: A History of the Duval County Medical Society and Medicine in Northeast Florida. Plan to purchase your copy of this coffee table size book with over 200 illustrations. It will be a collector’s item, but more than that...it will show how DCMS has always been a pioneer society led by its trailblazing membership. The same cutting edge spirit will take DCMS into 2012 and beyond! Watch for details on ordering the DCMS History Book to be available in 2012.

43 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Continued from p. 40

•

Religious Exemptions. This exemption allows religious organizations to exclude contraceptive services and was adopted as part of the issuance of the new guidelines in August for women’s health services. The religious exemption applies to not-for-profit groups that have the inculcation of religious values as their purpose, primarily employ individuals who hold certain religious beliefs, and primarily serve a population with those religious tenets. HHS has indicated that this exemption was modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception.

It looks like a phone. It acts like a personal health assistant.

How to Navigate the Requirements The best way for physicians to determine what benefits apply to a particular patient’s services is to check with the patient’s carrier or administrator and the same is true for finding the most accurate information regarding reimbursement. Nothing in the ACA establishes exactly how preventive care services may be reimbursed by the carrier in question. It just simply states that such services have to be covered as discussed earlier. Each carrier or administrator may have different policies and procedures regarding payment of preventive care claims including how to bill for such claims. Some of the policies may be influenced by whether or not the physician contracts with the carrier or administrator. For example, if a physician contracts on a capitated basis with a carrier, does the capitation rate previously negotiated include payment for these new preventive care services? Such questions will depend upon the physician’s specific contract.

Aetna Mobile is the #1 app in Health care1. Once you try it, it’s hard to imagine life without it. Try it out, healthyis.aetna.com/mobile. Know more. Get better.SM Based on public ranking data & iTunes® Connect, the Aetna Mobile App for the iPhone® mobile digital device has been the top ranked health insurance app in the “Healthcare and Fitness” category. Apple, the Apple logo, iPhone and iTunes are trademarks of Apple Inc., registered in the U.S. and other countries. ©2011 Aetna Inc. Plans offered by Aetna Life Insurance Company and its affiliates. Health benefits and insurance plans contain exclusions and limitations. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. 2011118 1

Did you know the NEFM Journal is online in a digital virtual version?

Future The preventive care guidelines will continue to evolve over time and as a result so will the coverage and benefits required by the ACA for preventive health services. It is important to continue to monitor the guidelines discussed that determine the definition of “preventive care” and to pay particular attention to the patient’s benefits as well as the effective date of any such changes.

...Go to dcmsonline.org, and "NEFM" at top, mouse down to "Current Issue" and over to "Current Issue" and click. The link to the "Virtual Edition" is at the top.

Click and "read" the journal online.

Check it Out! 44 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

A financial advisor dedicated to the medical industry can help you navigate changes in your practice’s finances. The business of medicine, much like your practice itself, is forever evolving. And with new financial opportunities and ongoing concerns — like protecting against fraud, managing risk and anticipating the impact of insurance and reimbursements on cash flow — you need the guidance of an advisor who uniquely understands your industry. At SunTrust, advisors with our Private Wealth Management Medical Specialty Group work solely with physicians and their practices to deliver solutions designed for the medical community. To schedule an appointment with an advisor, call 904.632.2854 or visit suntrust.com/medicine to learn more.

Treasury and Payment Solutions

Lending

Investments

Financial Planning

Deposit products and services are offered through SunTrust Bank, Member FDIC.

Securities and Insurance Products and Services: Are not FDIC or any other Government Agency Insured • Are not Bank Guaranteed • May Lose Value SunTrust Private Wealth Management Medical Specialty Group is a marketing name used by SunTrust Banks, Inc., and the following affiliates: Banking and trust products and services are provided by SunTrust Bank. Securities, insurance (including annuities and certain life insurance products) and other investment products and services are offered by SunTrust Investment Services, Inc., an SEC-registered investment adviser and broker/dealer and a member of FINRA and SIPC. Other insurance products and services are offered by SunTrust Insurance Services, Inc., a licensed insurance agency. ©2011 SunTrust Banks, Inc. SunTrust and Live Solid. Bank Solid. are federally registered service marks of SunTrust Banks, Inc.

45 Vol. 62, No. 4 2011 Northeast Florida Medicine

www . DCMS online . org

Introducing the

St Johns Vein Center

Dr. James St. George is proud to join the Jacksonville community, bringing more than 20 years experience in treating vascular disorders. The recent opening of the St Johns Vein Center provides you with a new option for patients suffering from lower extremity venous disease including: • Chronic venous insufficiency • Chronic distal skin changes including abnormal increased pigmentation, eczema, ulceration • Leg, ankle and foot swelling

• • • •

Leg pain, cramps, discomfort Restless legs Varicose veins Spider veins

Your patients no longer have to drive downtown for specialist vein care. Our state-of-the-art facility is conveniently located just off the Baymeadows road exit on 9A. We provide the following treatment options: • Radiofrequency ablation • Laser ablation • Ultrasound-guided chemical ablation

• Foam sclerotherapy • Liquid sclerotherapy • Ambulatory phlebectomy

We are a participating provider for Medicare, Tricare and most Commercial payers. Please visit www.stjohnsvein.com for more information or call (904) 402-VEIN (8346) to learn more about the care we can provide for your patients. James St. George, M.D. is a vascular specialist and a diplomat with the American Board of Radiology with a Certificate in Interventional Radiology. He completed his fellowship training at Harvard Medical School’s 9191 RG Skinner Parkway

•

Suite 303

w w w. stjo h n sve i n . com •

46 Vol. 62, No. 4 2011 Northeast Florida Medicine

Brigham and Women’s Hospital and served for 12 years as faculty at Harvard Medical School, Dartmouth Medical School and Drexal School of Medicine. He also held the position of Head of Special Procedures at Hahnemann Hospital in Philadelphia. Dr. St. George takes the time to know each patient and creates customized treatment programs to obtain the best possible results. •

Jacksonville, FL 32256

(904) 402-VEIN (8346) www . DCMS online . org

GIVE

Gift

YOUR PATIENTS A THIS HOLIDAY SEASON…

Quality Time with Family Now is the time to talk to your patients with advanced illness and their families about the benefits of Community Hospice care. By discussing these care options before the holidays, you offer them peace of mind that comes with greater comfort and more quality time together, allowing them to enjoy favorite traditions and make lasting memories. Call us today to find out how you can give this gift to your patients.Together, let’s make the holidays a cherished time for all to remember.

904.407.6500 • toll free 866.253.6681 • communityhospice.com Community Focused • Community Supported • Serving Baker, Clay, Duval, Nassau and St. Johns counties since 1979

Duval County Medical Society Foundation 555 Bishopgate Lane Jacksonville, FL 32204

NON-PROFIT ORGANIZATION

U.S. Postage Paid Jacksonville, Florida

Permit No. 2981

ADDRESS SERVICE REQUESTED

We proudly announce that First Professionals Insurance Company and The Doctors Company have united. Together, we set a higher standard. We aggressively defend your name. We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are the nationâ&#x20AC;&#x2122;s largest insurer of physician and surgeon medical liability. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

The Doctors Company and First Professionals Insurance Company (FPIC) have officially joined forces. With the addition of FPIC, we have grown in numbers, talent, and perspectiveâ&#x20AC;&#x201D; strengthening our ability to relentlessly defend, protect, and reward our 71,000 members nationwide. To learn more about how we can protect your livelihood and reputation with our medical professional liability program, call (800) 352-0320 or visit us at www.thedoctors.com.

We relentlessly defend, protect, and reward the practice of good medicine.